{
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"FirstLineMailingAddress": "6416 DEANS HILL RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BERRIEN CENTER",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "49102-9750",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "269-471-7741",
"MailingAddressFaxNumber": "269-471-1581",
"FirstLinePracticeLocationAddress": "42 N SAINT JOSEPH AVE",
"SecondLinePracticeLocationAddress": "SUITE 200",
"PracticeLocationAddressCityName": "NILES",
"PracticeLocationAddressStateName": "MI",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "269-684-5447",
"PracticeLocationAddressFaxNumber": "269-684-0256",
"EnumerationDate": "06/08/2011",
"LastUpdateDate": "07/13/2012",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CROCKER",
"AuthorizedOfficialFirstName": "JANCIE",
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"AuthorizedOfficialTitle": "DIRECTOR, PRACTICE OPERATIONS",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "268-687-1152",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "208800000X",
"TaxonomyName": "Urology Physician",
"LicenseNumber": "4301036136",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"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."
}
}
}
}