=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700301868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S HEALTH SYSTEM, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8375 S HOWELL AVE
-----------------------------------------------------
City | OAK CREEK
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53154-8344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-435-9431
-----------------------------------------------------
Fax | 414-764-6954
-----------------------------------------------------
=====================================================
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 | CORP VP & CHIEF FINANCIAL OFCR
-----------------------------------------------------
Name | MARC CADIEUX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-266-6226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------