Basic Information
| Provider Information | |||||||||
| NPI: | 1205281110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS HOSPITAL OF WISCONSIN INC | ||||||||
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| OtherOrganizationName: | CHILDRENS HOSPITAL OF WISCONSIN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1695 N JONES BLVD APT 10 | ||||||||
| Address2: | |||||||||
| City: | NORTH LIBERTY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 523178824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072510673 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8915 W CONNELL AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2016 | ||||||||
| LastUpdateDate: | 04/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | MIKHAILOV | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, PED. CRITICAL CARE NP | ||||||||
| AuthorizedOfficialTelephone: | 4142662438 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD,PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 123314 | IA | Y | Hospitals | General Acute Care Hospital | Children |
No ID Information.