{
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"EIN": null,
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"OtherLastNameTypeCode": "2",
"FirstLineMailingAddress": "6039 W BELMONT AVE",
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"MailingAddressCityName": "CHICAGO",
"MailingAddressStateName": "IL",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "847-266-9550",
"MailingAddressFaxNumber": "847-266-9144",
"FirstLinePracticeLocationAddress": "6039 W BELMONT AVE",
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"PracticeLocationAddressCityName": "CHICAGO",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "773-622-6095",
"PracticeLocationAddressFaxNumber": "773-622-8706",
"EnumerationDate": "02/13/2007",
"LastUpdateDate": "10/10/2018",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "General Practice Physician",
"LicenseNumber": "036-057827",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}