Healthcare Provider Details

I. General information

NPI: 1962507228
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6308 8TH AVE SIXTH FLOOR
KENOSHA WI
53143-5031
US

IV. Provider business mailing address

PO BOX 1997
MILWAUKEE WI
53201-1997
US

V. Phone/Fax

Practice location:
  • Phone: 262-656-2261
  • Fax: 262-653-5751
Mailing address:
  • Phone: 414-266-2000
  • Fax: 414-266-6409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number1003
License Number StateWI

VIII. Authorized Official

Name: MR. WELDON W GAGE
Title or Position: CFO/TREASURER
Credential:
Phone: 414-266-6401