{
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"FirstLineMailingAddress": "11114 W MEQUANIGO DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WEST ALLIS",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "53227-3051",
"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "620 BELL ST",
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"PracticeLocationAddressCityName": "WAUKESHA",
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"EnumerationDate": "09/11/2013",
"LastUpdateDate": "09/11/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CAINE",
"AuthorizedOfficialFirstName": "GLENN",
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"AuthorizedOfficialTitle": "PRESIDENT",
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"AuthorizedOfficialTelephoneNumber": "414-313-4652",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Family Medicine Physician",
"LicenseNumber": "34605",
"LicenseNumberStateCode": "WI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}