{
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"FirstLineMailingAddress": "1898 MCRAE LN",
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"MailingAddressCityName": "MUNDELEIN",
"MailingAddressStateName": "IL",
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"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "847-542-4868",
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"FirstLinePracticeLocationAddress": "1211 WASHINGTON AVE",
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"PracticeLocationAddressCityName": "WILMETTE",
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"EnumerationDate": "08/09/2012",
"LastUpdateDate": "08/09/2012",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "COLOSI",
"AuthorizedOfficialFirstName": "RICHARD",
"AuthorizedOfficialMiddleName": "BRYANT",
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"AuthorizedOfficialCredential": "DPT, FAFS, FMR",
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"TaxonomyName": "Point of Service",
"LicenseNumber": "070014101",
"LicenseNumberStateCode": "IL",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}