{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "INTERVENTIONAL & MULTI-DISCIPLINARY PAIN MANAGEMENT",
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"NamePrefix": null,
"NameSuffix": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 1523",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "STONY BROOK",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "11790-0907",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "631-444-0910",
"MailingAddressFaxNumber": "631-689-3814",
"FirstLinePracticeLocationAddress": "2500 NESCONSET HWY",
"SecondLinePracticeLocationAddress": "BLDG 24C",
"PracticeLocationAddressCityName": "STONY BROOK",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "11790-2555",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "631-444-0910",
"PracticeLocationAddressFaxNumber": "631-689-3814",
"EnumerationDate": "05/08/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ERMISH",
"AuthorizedOfficialFirstName": "LAURINE",
"AuthorizedOfficialMiddleName": "ANN",
"AuthorizedOfficialTitle": "OFFICE MANAGER",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "RN",
"AuthorizedOfficialTelephoneNumber": "631-941-0187",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "174400000X",
"TaxonomyName": "Specialist",
"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."
}
}
}
}