Healthcare Provider Details

I. General information

NPI: 1740455096
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: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6809 122ND AVE
KENOSHA WI
53142-7335
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 262-654-8633
  • Fax: 262-654-5467
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 GROUP
Credential: M.D.
Phone: 414-266-7615