Healthcare Provider Details

I. General information

NPI: 1780155275
Provider Name (Legal Business Name): CHILDREN'S HEALTH SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6809 122ND AVENUE
KENOSHA WI
54342-7335
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 262-891-6600
  • Fax: 262-891-6602
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARC CADIEUX
Title or Position: CORP VP & CHIEF FINANCIAL OFFICER
Credential:
Phone: 414-266-6226