Healthcare Provider Details

I. General information

NPI: 1831502327
Provider Name (Legal Business Name): CHILDREN'S MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3365 S 103RD ST STE 210
MILWAUKEE WI
53227-4108
US

IV. Provider business mailing address

9000 W WISCONSIN AVE MAIL STATION 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 262-814-7080
  • Fax: 262-432-9004
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
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