=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982770095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENOSHA FAMILY PRACTICE, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 02/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5923 GREEN BAY RD
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53144-3737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-652-0500
-----------------------------------------------------
Fax | 262-652-1928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5923 GREEN BAY RD
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53144-3737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-652-0500
-----------------------------------------------------
Fax | 262-652-1928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEPHEN P FEUERBACH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 262-652-0500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 30201
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------