Basic Information
| Provider Information | |||||||||
| NPI: | 1154597029 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S PHYSICIAN GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ALGONQUIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | MS 8000 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142667615 | ||||||||
| FaxNumber: | 4142663803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1473 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | ALGONQUIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601025916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476624380 | ||||||||
| FaxNumber: | 8476623557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2008 | ||||||||
| LastUpdateDate: | 06/26/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUNIGAN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CHILDREN'S PHYSICIAN GRP | ||||||||
| AuthorizedOfficialTelephone: | 4142667615 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDREN'S PHYSICIAN GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
No ID Information.