Basic Information
| Provider Information | |||||||||
| NPI: | 1194064865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HOSPITAL OF WISCONSIN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILD ADVOCACY CENTER - RACINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE | ||||||||
| Address2: | MS 958 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142667615 | ||||||||
| FaxNumber: | 4142666238 | ||||||||
| Practice Location | |||||||||
| Address1: | 2405 NORTHWESTERN AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | RACINE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 534042534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628987970 | ||||||||
| FaxNumber: | 2628986621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2013 | ||||||||
| LastUpdateDate: | 09/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | GAGE | ||||||||
| AuthorizedOfficialFirstName: | WELDON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4142666401 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.