Basic Information
| Provider Information | |||||||||
| NPI: | 1952408353 | ||||||||
| 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: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | CADIEUX | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 4142666226 | ||||||||
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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 | 261QE0700X | 135 | WI | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 11019700 | 05 | WI | MEDICAID |