Provider Demographics
NPI:1619392420
Name:CHILDREN'S HOSPITAL OF WISCONSIN, INC
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL OF WISCONSIN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:WELDON
Authorized Official - Middle Name:W
Authorized Official - Last Name:GAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-266-6401
Mailing Address - Street 1:PO BOX 1997
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1997
Mailing Address - Country:US
Mailing Address - Phone:414-266-2000
Mailing Address - Fax:414-266-6409
Practice Address - Street 1:999 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4875
Practice Address - Country:US
Practice Address - Phone:414-266-3303
Practice Address - Fax:414-266-1539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9244-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy