1205281110 NPI number — CHILDRENS HOSPITAL OF WISCONSIN INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205281110 NPI number — CHILDRENS HOSPITAL OF WISCONSIN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDRENS HOSPITAL OF WISCONSIN INC
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:
Provider Other Organization Name Type Code:
6
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:
1205281110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1695 N JONES BLVD APT 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH LIBERTY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52317-8824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-251-0673
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8915 W CONNELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-3067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-266-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MIKHAILOV
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PED. CRITICAL CARE NP
Authorized Official Telephone Number:
414-266-2438

Provider Taxonomy Codes

  • Taxonomy code: 282NC2000X , with the licence number:  123314 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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