Healthcare Provider Details

I. General information

NPI: 1205281110
Provider Name (Legal Business Name): CHILDRENS HOSPITAL OF WISCONSIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8915 W CONNELL AVE
MILWAUKEE WI
53226-3067
US

IV. Provider business mailing address

1695 N JONES BLVD APT 10
NORTH LIBERTY IA
52317-8824
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-2000
  • Fax:
Mailing address:
  • Phone: 507-251-0673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number123314
License Number StateIA

VIII. Authorized Official

Name: THERESA MIKHAILOV
Title or Position: DIRECTOR, PED. CRITICAL CARE NP
Credential: MD,PHD
Phone: 414-266-2438