{
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"OrgName": "SPINE NEUROSURGERY INST OF NE WI S.C.",
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"NamePrefix": null,
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"FirstLineMailingAddress": "3409 NICOLET DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GREEN BAY",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "54311-7203",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "920-846-8057",
"MailingAddressFaxNumber": "920-846-4588",
"FirstLinePracticeLocationAddress": "835 S MAIN ST",
"SecondLinePracticeLocationAddress": "SUITE 1",
"PracticeLocationAddressCityName": "OCONTO FALLS",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "54154-1282",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "920-846-8057",
"PracticeLocationAddressFaxNumber": "920-846-4588",
"EnumerationDate": "01/26/2006",
"LastUpdateDate": "10/20/2008",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PEREIRA",
"AuthorizedOfficialFirstName": "BRYAN",
"AuthorizedOfficialMiddleName": "M",
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"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "920-846-8057",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207T00000X",
"TaxonomyName": "Neurological Surgery Physician",
"LicenseNumber": "39920-20",
"LicenseNumberStateCode": "WI",
"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."
}
}
}
}