Healthcare Provider Details

I. General information

NPI: 1194064865
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 NORTHWESTERN AVE SUITE 205
RACINE WI
53404-2534
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 262-898-7970
  • Fax: 262-898-6621
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: WELDON GAGE
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 414-266-6401