{
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"NPI": "1841242823",
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"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"OrgName": "CHARLES S. THEOFILOS MD PA",
"LastName": null,
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"NameSuffix": null,
"Credential": null,
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"OtherOrgNameTypeCode": "6",
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "300 VILLAGE SQUARE XING STE 202",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PALM BEACH GARDENS",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33410-3223",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "561-630-3870",
"MailingAddressFaxNumber": "561-630-3680",
"FirstLinePracticeLocationAddress": "300 VILLAGE SQUARE XING STE 202",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "PALM BEACH GARDENS",
"PracticeLocationAddressStateName": "FL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "561-630-3870",
"PracticeLocationAddressFaxNumber": "561-630-3680",
"EnumerationDate": "05/17/2006",
"LastUpdateDate": "04/28/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "THEOFILOS",
"AuthorizedOfficialFirstName": "CHARLES",
"AuthorizedOfficialMiddleName": "S",
"AuthorizedOfficialTitle": "PHYSICIAN OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "561-630-3870",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207T00000X",
"TaxonomyName": "Neurological Surgery Physician",
"LicenseNumber": "XXXXXXXXXXXXXXXX",
"LicenseNumberStateCode": "FL",
"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."
}
}
}
}