Provider Demographics
NPI:1982770095
Name:KENOSHA FAMILY PRACTICE, S.C.
Entity Type:Organization
Organization Name:KENOSHA FAMILY PRACTICE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FEUERBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-652-0500
Mailing Address - Street 1:5923 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-3737
Mailing Address - Country:US
Mailing Address - Phone:262-652-0500
Mailing Address - Fax:262-652-1928
Practice Address - Street 1:5923 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-3737
Practice Address - Country:US
Practice Address - Phone:262-652-0500
Practice Address - Fax:262-652-1928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30201261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21270500Medicaid
DA2461OtherRAILROAD MEDICARE
WI21270500Medicaid
DA2461OtherRAILROAD MEDICARE