Provider Demographics
NPI:1467817320
Name:FAITHFUL PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:FAITHFUL PHYSICIAN SERVICES LLC
Other - Org Name:FAITHFUL PHYSICIAN SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MATHER
Authorized Official - Last Name:KOTSONIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-373-6733
Mailing Address - Street 1:12420 W HAMPTON AVE #89
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:WI
Mailing Address - Zip Code:53007-0089
Mailing Address - Country:US
Mailing Address - Phone:262-373-6733
Mailing Address - Fax:262-373-6018
Practice Address - Street 1:1109 CECELIA DRIVE
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-2524
Practice Address - Country:US
Practice Address - Phone:262-373-6733
Practice Address - Fax:262-373-6018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-20
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53437-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100031662Medicaid
WI100031662Medicaid