Healthcare Provider Details

I. General information

NPI: 1992810667
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE MSC 750
MILWAUKEE WI
53226-3518
US

IV. Provider business mailing address

9000 W WISCONSIN AVE MSC 750 PO BOX 1997
MILWAUKEE WI
53226-3518
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-2932
  • Fax: 414-266-3735
Mailing address:
  • Phone: 414-266-2932
  • Fax: 414-266-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number2530057
License Number StateWI

VIII. Authorized Official

Name: DR. BETH C LONG
Title or Position: PEDIATRIC PSYCHOLOGIST
Credential: PSYD
Phone: 414-266-3047