1124362306 NPI number — CHILDREN'S PHYSICIAN GROUP

Table of content: (NPI 1124362306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124362306 NPI number — CHILDREN'S PHYSICIAN GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S PHYSICIAN GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CRYSTAL LAKE CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124362306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9000 W WISCONSIN AVE
Provider Second Line Business Mailing Address:
MS 958
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-4874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-266-7615
Provider Business Mailing Address Fax Number:
414-266-6238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 STATION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-7978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-338-6600
Provider Business Practice Location Address Fax Number:
815-477-9826
Provider Enumeration Date:
11/12/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KHARE
Authorized Official First Name:
SMRITI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT, CHILDREN'S PHYSICIAN GRP
Authorized Official Telephone Number:
414-266-7615

Provider Taxonomy Codes

  • Taxonomy code: 2080P0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)