Healthcare Provider Details

I. General information

NPI: 1982770095
Provider Name (Legal Business Name): KENOSHA FAMILY PRACTICE, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5923 GREEN BAY RD
KENOSHA WI
53144-3737
US

IV. Provider business mailing address

5923 GREEN BAY RD
KENOSHA WI
53144-3737
US

V. Phone/Fax

Practice location:
  • Phone: 262-652-0500
  • Fax: 262-652-1928
Mailing address:
  • Phone: 262-652-0500
  • Fax: 262-652-1928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number30201
License Number StateWI

VIII. Authorized Official

Name: DR. STEPHEN P FEUERBACH
Title or Position: PRESIDENT
Credential: MD
Phone: 262-652-0500