Provider Demographics
NPI:1205281110
Name:CHILDRENS HOSPITAL OF WISCONSIN INC
Entity type:Organization
Organization Name:CHILDRENS HOSPITAL OF WISCONSIN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PED. CRITICAL CARE NP
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKHAILOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHD
Authorized Official - Phone:414-266-2438
Mailing Address - Street 1:1695 N JONES BLVD APT 10
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-8824
Mailing Address - Country:US
Mailing Address - Phone:507-251-0673
Mailing Address - Fax:
Practice Address - Street 1:8915 W CONNELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3067
Practice Address - Country:US
Practice Address - Phone:414-266-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA123314282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren