=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487616033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANIEL G KOSTER MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2006
-----------------------------------------------------
Last Update Date | 05/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 704 S WEBSTER AVE STE 1C
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301-3528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-433-3486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 704 S WEBSTER AVE STE 1C
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301-3528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-433-3486
-----------------------------------------------------
Fax | 920-433-7994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE COORDINATOR
-----------------------------------------------------
Name | SHERI L WANHALA-PAULSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-433-3486
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------