{
"Npi": {
"NPI": "1861206153",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "RENEW SPINE AND REHAB INC",
"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": "24725 W 12 MILE RD STE 260",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SOUTHFIELD",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48034-8310",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "248-353-2225",
"MailingAddressFaxNumber": "248-353-2239",
"FirstLinePracticeLocationAddress": "24725 W 12 MILE RD STE 260",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SOUTHFIELD",
"PracticeLocationAddressStateName": "MI",
"PracticeLocationAddressPostalCode": "48034-8310",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "248-353-2225",
"PracticeLocationAddressFaxNumber": "248-353-2239",
"EnumerationDate": "02/05/2025",
"LastUpdateDate": "02/05/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GLAZER",
"AuthorizedOfficialFirstName": "MORGAN",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "COO",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "248-353-2225",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "111NR0400X",
"TaxonomyName": "Rehabilitation Chiropractor",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "2251S0007X",
"TaxonomyName": "Sports Physical Therapist",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207PS0010X",
"TaxonomyName": "Sports Medicine (Emergency Medicine) Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}