Provider Demographics
NPI:1700222981
Name:CHILDREN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL GROUP
Other - Org Name:GREENSQUARE SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CHILDREN'S MEDICAL GROUP
Authorized Official - Prefix:
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 1:7300 S 13TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1832
Practice Address - Country:US
Practice Address - Phone:414-228-4800
Practice Address - Fax:414-247-0894
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty