Provider Demographics
NPI:1124362306
Name:CHILDREN'S PHYSICIAN GROUP
Entity Type:Organization
Organization Name:CHILDREN'S PHYSICIAN GROUP
Other - Org Name:CRYSTAL LAKE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CHILDREN'S PHYSICIAN GRP
Authorized Official - Prefix:DR
Authorized Official - First Name:SMRITI
Authorized Official - Middle Name:
Authorized Official - Last Name:KHARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-266-7615
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:MS 958
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:360 STATION DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7978
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:815-477-9826
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S PHYSICIAN GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty