Basic Information
| Provider Information | |||||||||
| NPI: | 1053602425 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HOSPITAL OF WISCOSNIN, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1997 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532011997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662000 | ||||||||
| FaxNumber: | 4142666219 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662000 | ||||||||
| FaxNumber: | 4142666219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | BIRKENSTOCK | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER/CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4142666401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 2417 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1750482022 | 05 | WI | MEDICAID |