Provider Demographics
NPI: | 1821738261 |
---|---|
Name: | CHILDREN'S MEDICAL GROUP |
Entity Type: | Organization |
Organization Name: | CHILDREN'S MEDICAL GROUP |
Other - Org Name: | |
Other - Org Type: | |
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: | 1432 W FOREST HOME AVE STE 400 |
Practice Address - Street 2: | |
Practice Address - City: | MILWAUKEE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53204-3228 |
Practice Address - Country: | US |
Practice Address - Phone: | 414-567-5402 |
Practice Address - Fax: | 414-567-5359 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-04-01 |
Last Update Date: | 2022-04-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |