Healthcare Provider Details

I. General information

NPI: 1104070234
Provider Name (Legal Business Name): CHILDRENS HOSPITAL OF WISCONSIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE
WAUWATOSA WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE
WAUWATOSA WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-3583
  • Fax:
Mailing address:
  • Phone: 414-266-3583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number1280-023
License Number StateWI

VIII. Authorized Official

Name: MR. DAVID HORZEWSKI
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 414-266-3583