Provider Demographics
NPI:1346727443
Name:CHILDREN'S HOSPITAL OF WISCONSIN
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL OF WISCONSIN
Other - Org Name:CHILD ADVOCACY CENTER - LAKESHORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:REUTEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-266-7615
Mailing Address - Street 1:9000 W WISCONSIN AVE # MS 958
Mailing Address - Street 2:
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 1:134 S FOSTER DR
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080-2005
Practice Address - Country:US
Practice Address - Phone:262-358-9080
Practice Address - Fax:262-268-2040
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HOSPITAL OF WISCONSIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty