{
"Npi": {
"NPI": "1831200815",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "NOVAMED SURGERY CENTER OF SANTA ROSA, 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": "1720 4TH ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SANTA ROSA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "95404-3602",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "707-546-8100",
"MailingAddressFaxNumber": "707-544-6438",
"FirstLinePracticeLocationAddress": "1720 4TH ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SANTA ROSA",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "95404-3602",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "707-546-8100",
"PracticeLocationAddressFaxNumber": "707-544-6438",
"EnumerationDate": "08/31/2006",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MACOMBER",
"AuthorizedOfficialFirstName": "SCOTT",
"AuthorizedOfficialMiddleName": "T.",
"AuthorizedOfficialTitle": "EXECUTIVE VP & CFO",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "312-780-3234",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QA1903X",
"TaxonomyName": "Ambulatory Surgical Clinic/Center",
"LicenseNumber": "APPLIED FOR",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}