Healthcare Provider Details

I. General information

NPI: 1124362306
Provider Name (Legal Business Name): CHILDREN'S PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2012
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 STATION DR
CRYSTAL LAKE IL
60014-7978
US

IV. Provider business mailing address

9000 W WISCONSIN AVE MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 815-338-6600
  • Fax: 815-477-9826
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SMRITI KHARE
Title or Position: PRESIDENT, CHILDREN'S PHYSICIAN GRP
Credential: MD
Phone: 414-266-7615