{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "ISLAND NEUROLOGICAL THERAPY, P.C.",
"LastName": null,
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"NamePrefix": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "922 N BROADWAY",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MASSAPEQUA",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "11758-2303",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "516-520-5507",
"MailingAddressFaxNumber": "516-520-5493",
"FirstLinePracticeLocationAddress": "922 N BROADWAY",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MASSAPEQUA",
"PracticeLocationAddressStateName": "NY",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "516-520-5507",
"PracticeLocationAddressFaxNumber": "516-520-5493",
"EnumerationDate": "06/10/2015",
"LastUpdateDate": "10/23/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "TRIVEDI",
"AuthorizedOfficialFirstName": "BIRENDRA",
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"AuthorizedOfficialTitle": "CEO",
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"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "516-520-5507",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QM2500X",
"TaxonomyName": "Medical Specialty Clinic/Center",
"LicenseNumber": "209199",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}