Provider Demographics
NPI:1053602425
Name:CHILDREN'S HOSPITAL OF WISCOSNIN, INC.
Entity type:Organization
Organization Name:CHILDREN'S HOSPITAL OF WISCOSNIN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER/CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BIRKENSTOCK
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:414-266-6219
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2000
Practice Address - Fax:414-266-6219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2417261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1750482022Medicaid