{
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"FirstLineMailingAddress": "PO BOX 39901",
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"MailingAddressCityName": "BELFAST",
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"MailingAddressCountryCode": "US",
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"MailingAddressFaxNumber": "941-629-8170",
"FirstLinePracticeLocationAddress": "2525 HARBOR BLVD STE 308",
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"PracticeLocationAddressCityName": "PORT CHARLOTTE",
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"PracticeLocationAddressFaxNumber": "941-629-8170",
"EnumerationDate": "09/13/2005",
"LastUpdateDate": "04/08/2025",
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "KROETSCH",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "888-360-2288",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Internal Medicine Physician",
"LicenseNumber": "ME77553",
"LicenseNumberStateCode": "FL",
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}
},
"HealthcareProviderTaxonomyGroups": {
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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."
}
}
}
}