Healthcare Provider Details

I. General information

NPI: 1245491851
Provider Name (Legal Business Name): CHILDREN'S PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1027 W PARK AVE
LIBERTYVILLE IL
60048-2550
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 847-367-2615
  • Fax: 847-367-1801
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-3803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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