{
"Npi": {
"NPI": "1467442152",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "STAT LAB, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2201 W SUDBURY DR",
"SecondLineMailingAddress": "SUITE A",
"MailingAddressCityName": "BLOOMINGTON",
"MailingAddressStateName": "IN",
"MailingAddressPostalCode": "47403-3737",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "812-332-8101",
"MailingAddressFaxNumber": "812-332-0435",
"FirstLinePracticeLocationAddress": "2201 W SUDBURY AVE",
"SecondLinePracticeLocationAddress": "SUITE A",
"PracticeLocationAddressCityName": "BLOOMINGTON",
"PracticeLocationAddressStateName": "IN",
"PracticeLocationAddressPostalCode": "47403-3737",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "812-332-8101",
"PracticeLocationAddressFaxNumber": "812-332-0435",
"EnumerationDate": "10/25/2005",
"LastUpdateDate": "04/03/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GEBELE",
"AuthorizedOfficialFirstName": "GENE",
"AuthorizedOfficialMiddleName": "P",
"AuthorizedOfficialTitle": "DIRECTOR",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "812-332-8101",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "291U00000X",
"TaxonomyName": "Clinical Medical Laboratory",
"LicenseNumber": "15D0360697",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}