{
"Npi": {
"NPI": "1881488773",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "PROACTIVE MD IL SC",
"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": "124 ALLAWOOD CT",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "SIMPSONVILLE",
"MailingAddressStateName": "SC",
"MailingAddressPostalCode": "29681-6207",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "864-501-0751",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1472 N GREEN MOUNT RD",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "O FALLON",
"PracticeLocationAddressStateName": "IL",
"PracticeLocationAddressPostalCode": "62269-3416",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "730-240-8040",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "04/07/2025",
"LastUpdateDate": "04/07/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KEMBLE",
"AuthorizedOfficialFirstName": "MARK",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "CMO",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "864-501-0751",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QP2300X",
"TaxonomyName": "Primary Care Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}