Provider Demographics
NPI:1992810667
Name:CHILDREN'S HOSPITAL OF WISCONSIN
Entity type:Organization
Organization Name:CHILDREN'S HOSPITAL OF WISCONSIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:414-266-3047
Mailing Address - Street 1:9000 W WISCONSIN AVE MSC 750
Mailing Address - Street 2:PO BOX 1997
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3518
Mailing Address - Country:US
Mailing Address - Phone:414-266-2932
Mailing Address - Fax:414-266-3735
Practice Address - Street 1:9000 W WISCONSIN AVE MSC 750
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3518
Practice Address - Country:US
Practice Address - Phone:414-266-2932
Practice Address - Fax:414-266-3735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2530057282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40962400Medicaid
WIOTH000Medicare UPIN