{
"Npi": {
"NPI": "1649610858",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "NIAGARA DERMATOLOGY ASSOCIATES LLC",
"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": "5320 MILITARY RD",
"SecondLineMailingAddress": "STE 104",
"MailingAddressCityName": "LEWISTON",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "14092-2149",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "716-205-8324",
"MailingAddressFaxNumber": "716-205-8593",
"FirstLinePracticeLocationAddress": "5320 MILITARY RD",
"SecondLinePracticeLocationAddress": "STE 104",
"PracticeLocationAddressCityName": "LEWISTON",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "14092-2149",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "716-205-8324",
"PracticeLocationAddressFaxNumber": "716-205-8593",
"EnumerationDate": "07/02/2013",
"LastUpdateDate": "01/09/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MILLER",
"AuthorizedOfficialFirstName": "CRAIG",
"AuthorizedOfficialMiddleName": "CAMERON",
"AuthorizedOfficialTitle": "MEMBER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D., PH.D.",
"AuthorizedOfficialTelephoneNumber": "716-205-8324",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207N00000X",
"TaxonomyName": "Dermatology Physician",
"LicenseNumber": "211871",
"LicenseNumberStateCode": "NY",
"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."
}
}
}
}