Basic Information
| Provider Information | |||||||||
| NPI: | 1750482022 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HOSPITAL OF WISCONSIN, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1997 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532011997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662000 | ||||||||
| FaxNumber: | 4142666409 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142662000 | ||||||||
| FaxNumber: | 4142666409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | RICCA | ||||||||
| AuthorizedOfficialFirstName: | MONICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 4142662511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 135 | WI | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 291U00000X | 135 | WI | N | Laboratories | Clinical Medical Laboratory | 332B00000X | 135 | WI | N | Suppliers | Durable Medical Equipment & Medical Supplies | 282NC2000X | 135 | WI | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | 119026105 | 05 | AR | MEDICAID | XHSP33461 | 05 | CA | MEDICAID | 01509640 | 05 | NY | MEDICAID | 00095382 | 05 | MS | MEDICAID | 00435179X | 05 | GA | MEDICAID | 01700160 | 05 | KY | MEDICAID | 100037470A | 05 | IN | MEDICAID | 6014253 | 05 | OH | MEDICAID | XHSP43461 | 05 | CA | MEDICAID | 11019700 | 05 | WI | MEDICAID | 30-4655055 | 05 | MI | MEDICAID | 013436506 | 05 | MO | MEDICAID | 0944108 | 05 | IA | MEDICAID | D0927520-00 | 05 | MN | MEDICAID | 11530400 | 05 | FL | MEDICAID | 40-4655064 | 05 | MI | MEDICAID | 01 86806201 | 05 | KS | MEDICAID |