{
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"FirstLineMailingAddress": "PO BOX 1159",
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"MailingAddressCityName": "OLIVE BRANCH",
"MailingAddressStateName": "MS",
"MailingAddressPostalCode": "38654-0940",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "662-890-5559",
"MailingAddressFaxNumber": "662-893-8323",
"FirstLinePracticeLocationAddress": "6831 CRUMPLER BLVD",
"SecondLinePracticeLocationAddress": "SUITE 100",
"PracticeLocationAddressCityName": "OLIVE BRANCH",
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"PracticeLocationAddressFaxNumber": "662-893-8323",
"EnumerationDate": "02/26/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "RYAN",
"AuthorizedOfficialFirstName": "CHARLES",
"AuthorizedOfficialMiddleName": "G",
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"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "662-890-5559",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Obstetrics & Gynecology Physician",
"LicenseNumber": "16676",
"LicenseNumberStateCode": "MS",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}