Healthcare Provider Details

I. General information

NPI: 1356517221
Provider Name (Legal Business Name): CHILDREN'S PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 RIDGE AVE SUITE 109
EVANSTON IL
60201-2455
US

IV. Provider business mailing address

9000 W WISCONSIN AVE MS 8000
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 847-662-4380
  • Fax: 847-662-3557
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-3803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State

VIII. Authorized Official

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