{
"Npi": {
"NPI": "1508375064",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "CIVIC WILTON, PLLC",
"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": "249 DANBURY RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WILTON",
"MailingAddressStateName": "CT",
"MailingAddressPostalCode": "06897-4070",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "816-537-3431",
"MailingAddressFaxNumber": "816-537-3431",
"FirstLinePracticeLocationAddress": "249 DANBURY ROAD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "WILTON",
"PracticeLocationAddressStateName": "CT",
"PracticeLocationAddressPostalCode": "06897",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "816-537-3433",
"PracticeLocationAddressFaxNumber": "816-537-3431",
"EnumerationDate": "09/27/2017",
"LastUpdateDate": "06/22/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ROTEMAN",
"AuthorizedOfficialFirstName": "ROBERT",
"AuthorizedOfficialMiddleName": "M",
"AuthorizedOfficialTitle": "PARTNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "816-537-3433",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "207LP2900X",
"TaxonomyName": "Pain Medicine (Anesthesiology) Physician",
"LicenseNumber": "039079",
"LicenseNumberStateCode": "CT",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM1300X",
"TaxonomyName": "Multi-Specialty Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}