Provider Demographics
NPI:1275961021
Name:CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Other - Org Name:CHW PAIN AND HEADACHE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER/CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WELDON
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-266-6401
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:MAIL STATION 958 - SHEILA REUTEMAN
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 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PAIN CLINIC AND HEADACHE CLINIC
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-3133
Practice Address - Fax:414-266-1761
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-14
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3186-57103T00000X
WI662-124106H00000X
261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275961021Medicaid