{
"Npi": {
"NPI": "1508125170",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "KENNETH A. BERDICK, M.D., P.A.",
"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": "3714 EVANS AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "FORT MYERS",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33901-9303",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "239-334-4157",
"MailingAddressFaxNumber": "239-334-1904",
"FirstLinePracticeLocationAddress": "3714 EVANS AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "FORT MYERS",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "33901-9303",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "239-334-4157",
"PracticeLocationAddressFaxNumber": "239-334-1904",
"EnumerationDate": "05/16/2012",
"LastUpdateDate": "09/24/2012",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BERDICK",
"AuthorizedOfficialFirstName": "KENNETH",
"AuthorizedOfficialMiddleName": "A",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "239-334-4157",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "363LP0200X",
"TaxonomyName": "Pediatric Nurse Practitioner",
"LicenseNumber": "NP1971252",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207R00000X",
"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": "ME0017772",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}