npi provider organization name provider last name provider first name provider middle name provider name prefix provider name suffix provider credential provider other organization name provider other organization name type code provider other last name provider other first name provider other midedle name provider other name prefix provider other name suffix provider other credential provider last name type code provider first line business mailing address provider second line business mailing address provider business mailing address city provider business mailing address state provider business mailing address postal code provider business mailing address country provider business mailing address phone provider busines mailing address fax provider first line business practice address provider second line business practice address provider business practice address city provider business practice address postal code provider business practice address state provider business practice address country provider business practice address phone provider business practice address fax authorized official last name authorized official first name authorized official middle name authorized official title authorized official phone taxonomy code 1 taxonomy code 2 taxonomy code 3 taxonomy code 4 taxonomy code 5 taxonomy code 6 taxonomy code 7 taxonomy code 8 taxonomy code 9 taxonomy code 10 taxonomy code 11 taxonomy code 12 taxonomy code 13 taxonomy code 14 taxonomy code 15