{
"Npi": {
"NPI": "1538521083",
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"ReplacementNPI": null,
"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "GRAND RAPIDS SURGICAL ASSOCIATES, PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "1009 44TH ST SW",
"SecondLineMailingAddress": "STE 101",
"MailingAddressCityName": "WYOMING",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "49509-4480",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "616-828-4622",
"MailingAddressFaxNumber": "616-635-2552",
"FirstLinePracticeLocationAddress": "1009 44TH ST SW",
"SecondLinePracticeLocationAddress": "STE 101",
"PracticeLocationAddressCityName": "WYOMING",
"PracticeLocationAddressStateName": "MI",
"PracticeLocationAddressPostalCode": "49509-4480",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "616-828-4622",
"PracticeLocationAddressFaxNumber": "616-635-2552",
"EnumerationDate": "03/23/2016",
"LastUpdateDate": "07/06/2016",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PIHL",
"AuthorizedOfficialFirstName": "KERENT",
"AuthorizedOfficialMiddleName": "DOMINIQUE",
"AuthorizedOfficialTitle": "SURGEON/FOUNDER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.O.",
"AuthorizedOfficialTelephoneNumber": "616-634-0936",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "208600000X",
"TaxonomyName": "Surgery Physician",
"LicenseNumber": "5101019176",
"LicenseNumberStateCode": "MI",
"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."
}
}
}
}