{
"Npi": {
"NPI": "1669727921",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "KERWEL",
"FirstName": "THERESE",
"MiddleName": "G.",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "MD",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": "GANNON",
"OtherFirstName": "THERESE",
"OtherMiddleName": "ANN",
"OtherNamePrefix": "DR.",
"OtherNameSuffix": null,
"OtherCredential": "MD",
"OtherLastNameTypeCode": "1",
"FirstLineMailingAddress": "17000 W NORTH AVE",
"SecondLineMailingAddress": "SUITE 107W",
"MailingAddressCityName": "BROOKFIELD",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "53005-4423",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "262-785-7740",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "17000 W NORTH AVE",
"SecondLinePracticeLocationAddress": "SUITE 107W",
"PracticeLocationAddressCityName": "BROOKFIELD",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "53005-4423",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "262-785-7740",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "07/23/2012",
"LastUpdateDate": "01/25/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "208C00000X",
"TaxonomyName": "Colon & Rectal Surgery Physician",
"LicenseNumber": "61146",
"LicenseNumberStateCode": "WI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}