{
"Npi": {
"NPI": "1710126271",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SURGICAL GROUP PROF CORP",
"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": "157 BROADWAY",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "AMITYVILLE",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "11701-2729",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "631-598-7757",
"MailingAddressFaxNumber": "631-598-7759",
"FirstLinePracticeLocationAddress": "157 BROADWAY",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "AMITYVILLE",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "11701-2729",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "631-598-7757",
"PracticeLocationAddressFaxNumber": "631-598-7759",
"EnumerationDate": "02/06/2009",
"LastUpdateDate": "02/06/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "NUSSBAUM",
"AuthorizedOfficialFirstName": "JEFFREY",
"AuthorizedOfficialMiddleName": "K",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "631-598-7757",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "2086S0129X",
"TaxonomyName": "Vascular Surgery Physician",
"LicenseNumber": "147879",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "208600000X",
"TaxonomyName": "Surgery Physician",
"LicenseNumber": "147879",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}