{
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"OrgName": "MEXICO CARDIOVASCULAR ASSOCIATES LLC",
"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
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"FirstLineMailingAddress": "720 MEDICAL PARK DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MEXICO",
"MailingAddressStateName": "MO",
"MailingAddressPostalCode": "65265-3726",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "573-581-3240",
"MailingAddressFaxNumber": "573-581-7493",
"FirstLinePracticeLocationAddress": "720 MEDICAL PARK DR",
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"PracticeLocationAddressCityName": "MEXICO",
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"PracticeLocationAddressPostalCode": "65265-3726",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "573-581-3240",
"PracticeLocationAddressFaxNumber": "573-581-7493",
"EnumerationDate": "07/23/2006",
"LastUpdateDate": "05/21/2015",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "TILLMAN",
"AuthorizedOfficialFirstName": "CHARLES",
"AuthorizedOfficialMiddleName": "HERBERT",
"AuthorizedOfficialTitle": "OWNER/PARTNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "M.D.",
"AuthorizedOfficialTelephoneNumber": "573-581-3240",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "207RC0000X",
"TaxonomyName": "Cardiovascular Disease Physician",
"LicenseNumber": "36412",
"LicenseNumberStateCode": "MO",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}