=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346727443
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S HOSPITAL OF WISCONSIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2018
-----------------------------------------------------
Last Update Date | 07/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 S FOSTER DR
-----------------------------------------------------
City | SAUKVILLE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53080-2005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-358-9080
-----------------------------------------------------
Fax | 262-268-2040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9000 W WISCONSIN AVE # MS 958
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53226-4874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-266-7615
-----------------------------------------------------
Fax | 414-266-6238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | SHEILA REUTEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-266-7615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------