{
"Npi": {
"NPI": "1891712493",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "NORTHRIDGE FAMILY PRACTICE 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": "PO BOX 279",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "HALE",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48739-0279",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "989-728-6000",
"MailingAddressFaxNumber": "989-728-6003",
"FirstLinePracticeLocationAddress": "3190 NORTHRIDGE DRIVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "HALE",
"PracticeLocationAddressStateName": "MI",
"PracticeLocationAddressPostalCode": "48739-9276",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "989-728-6000",
"PracticeLocationAddressFaxNumber": "989-728-6003",
"EnumerationDate": "07/17/2006",
"LastUpdateDate": "11/02/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "PROVOAST",
"AuthorizedOfficialFirstName": "DEBRA",
"AuthorizedOfficialMiddleName": "KAYE",
"AuthorizedOfficialTitle": "MANAGING OFFICER",
"AuthorizedOfficialNamePrefix": "MRS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "RN MSN FNP",
"AuthorizedOfficialTelephoneNumber": "989-728-6000",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "207R00000X",
"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": "4301061417",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "4704148660",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363LF0000X",
"TaxonomyName": "Family Nurse Practitioner",
"LicenseNumber": "4704245250",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363LF0000X",
"TaxonomyName": "Family Nurse Practitioner",
"LicenseNumber": "4704283185",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "363L00000X",
"TaxonomyName": "Nurse Practitioner",
"LicenseNumber": "4704173663",
"LicenseNumberStateCode": "MI",
"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."
},
{
"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."
}
]
}
}
}