Healthcare Provider Details

I. General information

NPI: 1134394471
Provider Name (Legal Business Name): CHILDREN'S MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W SILVER SPRING DR SUITE C
GLENDALE WI
53209-4218
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 414-393-1925
  • Fax: 414-393-1926
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-1853

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. SMRITI KHARE
Title or Position: PRESIDENT, CHILDREN'S MEDICAL GRUOP
Credential: M.D.
Phone: 414-266-7615