Basic Information
| Provider Information | |||||||||
| NPI: | 1891416269 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S MEDICAL GROUP, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDREN'S WISCONSIN MENTAL HEALTH CONNECTIONS CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 W WISCONSIN AVE # MS 958 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142667615 | ||||||||
| FaxNumber: | 4142666238 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W WISCONSIN AVE STE 240 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143373400 | ||||||||
| FaxNumber: | 4143373409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2022 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | KHARE | ||||||||
| AuthorizedOfficialFirstName: | SMRITI | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CHILDREN'S MEDICAL GROUP | ||||||||
| AuthorizedOfficialTelephone: | 4147645726 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDREN'S MEDICAL GROUP, INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.