Provider Demographics
NPI:1962507228
Name:CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Other - Org Name:CHILDREN'S HOSPITAL OF WISCONSIN, INC. - KENOSHA
Other - Org Type:Doing Business As
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 1:6308 8TH AVE
Practice Address - Street 2:SIXTH FLOOR
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-656-2261
Practice Address - Fax:262-653-5751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1003282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11023000Medicaid
WI11023000Medicaid