Provider Demographics
NPI:1275708539
Name:CHILDREN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL GROUP
Other - Org Name:KENOSHA PEDS - PADDOCK LAKE SITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CHILDREN'S MEDICAL GROUP
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:414-266-1853
Practice Address - Street 1:24906 75TH ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WI
Practice Address - Zip Code:53168-9705
Practice Address - Country:US
Practice Address - Phone:262-843-2378
Practice Address - Fax:262-843-3053
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-28
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32854500Medicaid