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General NPI Number Information
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NPI Number | 1467817320
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Entity Type | Organization
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Legal Business Name | FAITHFUL PHYSICIAN SERVICES LLC
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Dates
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Enumeration Date | 12/20/2015
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Last Update Date | 06/27/2018
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Provider Practice Location Address
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Address Line | 1109 CECELIA DRIVE
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City | PEWAUKEE
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State | WI
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Zip | 53072-2524
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Country | US
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Telephone | 262-373-6733
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Fax | 262-373-6018
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Provider Business Mailing Address
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Address Line | 12420 W HAMPTON AVE #89
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City | BUTLER
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State | WI
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Zip | 53007-0089
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Country | US
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Telephone | 262-373-6733
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Fax | 262-373-6018
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEVEN MATHER KOTSONIS
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Credential | M.D.
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Telephone | 262-373-6733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 53437-20
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License Number State | WI
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