{
"Npi": {
"NPI": "1902021827",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "RUSSELL E. GILLIOM, D.D.S., P.C.",
"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 265",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CHURUBUSCO",
"MailingAddressStateName": "IN",
"MailingAddressPostalCode": "46723-0265",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "260-693-2177",
"MailingAddressFaxNumber": "260-693-6422",
"FirstLinePracticeLocationAddress": "230 E WHITLEY ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHURUBUSCO",
"PracticeLocationAddressStateName": "IN",
"PracticeLocationAddressPostalCode": "46723-1506",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "260-693-2177",
"PracticeLocationAddressFaxNumber": "260-693-6422",
"EnumerationDate": "04/16/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GILLIOM",
"AuthorizedOfficialFirstName": "RUSSELL",
"AuthorizedOfficialMiddleName": "E.",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "D.D.S.",
"AuthorizedOfficialTelephoneNumber": "260-693-2177",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QD0000X",
"TaxonomyName": "Dental Clinic/Center",
"LicenseNumber": "54000935A",
"LicenseNumberStateCode": "IN",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}