{
"Npi": {
"NPI": "1821319575",
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "HEALTHSOURCE MEDICAL SERVICES MEDFORD, PLLC",
"LastName": null,
"FirstName": null,
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"NamePrefix": null,
"NameSuffix": null,
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"FirstLineMailingAddress": "3001 EXPRESS DR N",
"SecondLineMailingAddress": "SUITE 200C",
"MailingAddressCityName": "ISLANDIA",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "11749-5301",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "631-435-0110",
"MailingAddressFaxNumber": "631-435-4583",
"FirstLinePracticeLocationAddress": "1743 N OCEAN AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "MEDFORD",
"PracticeLocationAddressStateName": "NY",
"PracticeLocationAddressPostalCode": "11763-2649",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "631-758-3100",
"PracticeLocationAddressFaxNumber": "631-758-3168",
"EnumerationDate": "06/17/2010",
"LastUpdateDate": "06/17/2010",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FOLAN",
"AuthorizedOfficialFirstName": "JOHN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PRESIDENT/OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "631-435-0110",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207R00000X",
"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": "167755",
"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."
}
}
}
}