Covered Entity Details

PED523300-66 CHILDREN'S HOSPITAL OF WISCONSIN, INC. (Active) - information as of 5/13/2025 1:47:27 AM

Main Details

Name

CHILDREN'S HOSPITAL OF WISCONSIN, INC.

Subdivision Name

Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Orthopedics (CC9348) - KNO Orthopedics (CC9348)

Type

Children's Hospital

Rural

340B ID

PED523300-66

Medicare Provider Number

523300

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/14/2022

Participating Start Date

10/1/2022

Participating Approval Date

8/3/2022

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Children's Hospital of Wisconsin
Scott Turner, COO CHW and EVP CHHS
(414) 266-2648

Primary Contact

Children's Wisconsin
Megan Elizabeth Ose, Director of Pharmacy Services
(414) 266-5773

Addresses

Street Address

6809 122ND AVENUE
KENOSHA, WI 53142

Billing Address

Children's Hospital of Wisconsin
9000 W Wisconsin Avenue
Milwaukee, WI 53226

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
WI	11019700	1750482022

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
PED523300-01	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN - GREENFIELD ORTHOPEDICS (CC8720)	3365 S 103RD STREET	MILWAUKEE	WI	Active
PED523300-02	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN SPECIALTY CLINICS (AKA:SPECIALTY CLINICS AT SINAI-SAMARITAN-DTHC, CHILD PROTECTION, DENTAL CTR)	1020 NORTH 12TH STREET	MILWAUKEE	WI	Terminated
PED523300-03	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN CLINICS- NEW BERLIN	4855 S MOORLAND ROAD	NEW BERLIN	WI	Terminated
PED523300-04	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics - Delafield / Outpatient hospital specialty clinic	3195 Hillside Drive	Delafield	WI	Terminated
PED523300-05	Child	PED	CHILDRENS HOSPITAL OF WISCONSIN	Children's Hospital of Wisconsin Clinics - Foxpoint / Outpatient hospital specialty service	7950 N Port Washington Road	Foxpoint	WI	Terminated
PED523300-06	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Audiology (CC8975)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-07	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic-Urology (CC8972)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-08	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Diag Neurology (CC8974)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-09	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Cleft (CC8976)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-10	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Diag Cardiology (CC8973)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-11	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic-Surgery (CC8971)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-12	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic-PFT Lab (CC8969)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-13	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - ENT (CC8965)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-14	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Asthma Allergy (CC8963)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-15	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Cardiology (CC8962)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-16	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic-Endocrine (CC8968)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-17	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Dermatology (CC8961)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-18	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - GI (CC8977)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-19	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic -PT/OT (CC8764)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-20	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic-Behavioral Health (CC8967)	4855 S MOORLAND RD	NEW BERLIN	WI	Terminated
PED523300-21	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Sleep Center (CC8763)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-22	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Lab (CC8762)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-23	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic-Pulmonary (CC8966)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-24	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Genetics (CC8978)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-25	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinc - Radiology (CC8761)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-26	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - Orthopedics (CC8957)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-27	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Speech (CC8979)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-28	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Greenfield Clinic-Physical Therapy (CC8722)	3365 S 103RD ST	MILWAUKEE	WI	Active
PED523300-29	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - ENT (CC8955)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-30	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Greenfield Clinic-Radiology (CC8721)	3365 S 103RD ST	MILWAUKEE	WI	Active
PED523300-31	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - Dermatology (CC8954)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-32	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic Asthma Allergy (CC8943)	3195 HILLSIDE DR	DELAFIELD	WI	Terminated
PED523300-33	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - Diagnostic Cardiology (CC8953)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-34	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Neurology (CC8980)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-35	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - Cardiology (CC8952)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-36	Child	PED	CHILDRENS HOSPITAL OF WISCONSIN	CHILDRENS HOSPITAL OF WISCONSIN INC / Fox Point Clinic-Dermatology	7950N PORT WASHINGTON RD 100	FOX POINT	WI	Terminated
PED523300-37	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / New Berlin Clinic - Pain Headache Clinic (CC8982)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-38	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - Imaging (CC8951)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-39	Child	PED	CHILDRENS HOSPITAL OF WISCONSIN	CHILDRENS HOSPITAL OF WISCONSIN INC / Fox Point Clinic-Pulmonary	7950N PORT WASHINGTON RD 100	FOX POINT	WI	Terminated
PED523300-40	Child	PED	CHILDRENS HOSPITAL OF WISCONSIN	CHILDRENS HOSPITAL OF WISCONSIN INC / Fox Point Clinic-Speech	7950N PORT WASHINGTON RD 100	FOX POINT	WI	Terminated
PED523300-41	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - General Surgery (CC8950)	3195 HILLSIDE DR	DELAFIELD	WI	Terminated
PED523300-42	Child	PED	CHILDRENS HOSPITAL OF WISCONSIN	CHILDRENS HOSPITAL OF WISCONSIN INC / Fox Point Clinic-Diagnostic Cardiology (CC8940)	7950N PORT WASHINGTON RD 100	FOX POINT	WI	Terminated
PED523300-43	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - Audiology (CC8949)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-44	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - Speech (CC8948)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-45	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - Physical Therapy (CC8947)	3195 HILLSIDE DR	DELAFIELD	WI	Terminated
PED523300-46	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDRENS HOSPITAL OF WISCONSIN INC / Delafield Clinic - Pulmonary Function (CC8945)	3195 HILLSIDE DR	DELAFIELD	WI	Terminated
PED523300-47	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - Asthma Allergy (cc9215)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-48	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - Urology (cc9229)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-49	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - Orthopedics (cc9226)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-50	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - Dermatology (cc9218)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-51	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - Ophthalmology (cc9225)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-52	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - ENT (cc9221)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-53	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - Neurology (cc9228)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-54	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - Surgery (cc9211)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-55	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - GI (cc9220)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-56	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	CHILDREN'S HOSPITAL OF WISCONSIN-ME - Mequon Clinic - Cardiology (cc9216)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-57	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Endocrine (CC9334) - KNO Endocrine (CC9334)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-58	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / New Berlin Rehab Clinic (CC8766) - NB Rehab (CC8766)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-59	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Rehab (CC9335) - KNO Rehab (CC9335)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-60	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Diabetes Clinic (CC9347) - KNO Diabetes Clinic (CC9347)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-61	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Speech (CC9331) - KNO Speech (CC9331)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-62	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Pulmonary Function Test (CC9339) - KNO Pulmonary Function Test (CC9339)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-63	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Imaging (CC9343) - KNO Imaging (CC9343)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-64	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic ENT (CC9336) - KNO ENT (CC9336)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-65	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Urology (CC9332) - KNO Urology (CC9332)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-66	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Orthopedics (CC9348) - KNO Orthopedics (CC9348)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-67	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Delafield Clinic Neurology (CC8986) - DC Neurology (CC8986)	3195 HILLSIDE DR	DELAFIELD	WI	Terminated
PED523300-68	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Diag Neurology (CC9342) - KNO Diag Neurology (CC9342)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-69	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Delafield Clinic Diag Neurology (CC8987) - DC Diag Neurology (CC8987)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-70	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Asthma Allergy (CC9325) - KNO Asthma Allergy (CC9325)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-71	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / New Berlin Eye Clinic (CC8970) - NB Eye Clinic (CC8970)	4855 S MOORLAND RD	NEW BERLIN	WI	Active
PED523300-72	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Greenfield Clinic Audiology (CC8728) - Greenfield Audiology (CC8728)	3365 S 103rd Street	Milwaukee	WI	Active
PED523300-73	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Delafield Clinic Gastroenterology (CC8956) - DC Gastroenterology (CC8956)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-74	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Cardiology (CC9326) - KNO Cardiology (CC9326)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-75	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Delafield Clinic Craniofacial Surgery (CC8959) - DC Craniofacial Surgery (CC8959)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-76	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Diag Cardiology (CC9327) - KNO Diag Cardiology (CC9327)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-77	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Neurology (CC9341) - KNO Neurology (CC9341)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-78	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha PT/OT Developmental (CC9340) - KNO PT/OT Developmental (CC9340)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-79	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic Imaging (CC9236) - MEQ Imaging (CC9236)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-80	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Greenfield Clinic ENT (CC8725) - Greenfield Clinic ENT (CC8725)	3365 S 103rd Street	Milwaukee	WI	Active
PED523300-81	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic Pulmonary (CC9224) - MEQ Pulmonary (CC9224)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-82	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Audiology (CC9337) - KNO Audiology (CC9337)	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-83	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic Behavioral Health (CC9230) - MEQ Behavioral Health (CC9230)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-84	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Delafield Clinic Urology (CC8958) - DC Urology (CC8958)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-85	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Delafield Clinic PT/OT Develop (CC8922) - DC PT/OT Develop (CC8922)	3195 HILLSIDE DR	DELAFIELD	WI	Active
PED523300-86	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic Pulmonary Function Test (CC9233) - Mequon Clinic - Pulmonary Function Test (cc9233)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-87	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic PT/OT Develop (CC9232) - MEQ Clinic PT/OT Develop (CC9232)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-88	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic PT/OT Sports (CC9231) - MEQ Clinic PT/OT Sports (CC9231)	1655 W MEQUON RD	MEQUON	WI	Terminated
PED523300-89	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic Speech (CC9222) - MEQ Clinic Speech (CC9222)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-90	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic Audiology (CC9223) - MEQ Clinic Audiology (CC9223)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-91	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic Diagnostic / Neuro (CC9234) - MEQ Clinic Diagnostic / Neuro (CC9234)	1655 W Mequon Road	MEQUON	WI	Active
PED523300-92	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Dermatology (CC9328) - Dermatology	6809 122ND AVENUE	KENOSHA	WI	Active
PED523300-93	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Kenosha Laboratory (CC9344) - KNO Lab (CC9344)	6809 122ND AVENUE	Kenosha	WI	Active
PED523300-94	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Delafield Clinic Laboratory (CC8944) - Lab	3195 HILLSIDE DR	Delafield	WI	Active
PED523300-95	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic Laboratory (CC9237) - Mequon Clinic Laboratory (CC9237)	1655 W MEQUON RD	MEQUON	WI	Active
PED523300-96	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin, Inc. - Kenosha Clinic - GI (CC9330) - Kenosha GI	6809 122ND AVENUE	Kenosha	WI	Active
PED523300-97	Child	PED	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	Children's Hospital of Wisconsin Clinics Inc / Mequon Clinic Cardiology Diagnostics (CC9217) - Mequon Clinic - Cardiology Diagnostics (CC9217)	1655 W MEQUON RD	Mequon	WI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 1:04:16 PM	8/28/2024 1:19:56 PM	8/28/2024 1:19 PM
Details	Last Recertification Date	Update	Recertification		9/5/2023 1:04:16 PM	9/5/2023 1:04 PM
Details	State	Update		Approved	Active	10/1/2022 12:01 AM
Addresses	Shipping Address	Delete	Change Request	Children's Hospital of Wisconsin 9000 W Wisconsin Avenue Milwaukee, WI 53226		8/17/2022 9:51 AM
Contacts	Primary Contact	Update	Profile Change Request	Ose, Megan Elizabeth Pharmacy Operations Manager Children's Wisconsin 4142665773	Ose, Megan Elizabeth Director of Pharmacy Services Children's Wisconsin 4142665773	8/15/2022 1:54 PM
Contacts	Signed By	Insert	New Registration		Turner, Scott COO CHW and EVP CHHS Children's Hospital of Wisconsin 4142662648	8/3/2022 3:41 PM
Details	340B ID	Update	New Registration		PED523300-66	8/3/2022 3:41 PM
Details	Entity Name	Update	New Registration	CHILDRENS HOSPITAL OF WISCONSIN	CHILDREN'S HOSPITAL OF WISCONSIN, INC.	8/3/2022 3:41 PM
Details	Entity Subname	Update	New Registration	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Orthopedics (CC9348)	Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Orthopedics (CC9348) - KNO Orthopedics (CC9348)	8/3/2022 3:41 PM
Dates	Participating Approval Date	Update	New Registration		8/3/2022 3:41:21 PM	8/3/2022 3:41 PM
Details	State	Update	New Registration	Pending	Approved	8/3/2022 3:41 PM
Dates	Signed By Date	Update	New Registration		7/15/2022 11:40:09 AM	8/3/2022 3:41 PM
Dates	Start Date	Update	New Registration		10/1/2022 12:00:00 AM	8/3/2022 3:41 PM
Addresses	Main Address	Insert	New Registration		6809 122ND AVENUE KENOSHA, WI 53142	7/14/2022 9:08 PM
Addresses	Billing Address	Insert	New Registration		Children's Hospital of Wisconsin 9000 W Wisconsin Avenue Milwaukee, WI 53226	7/14/2022 9:08 PM
Addresses	Shipping Address	Insert	New Registration		Children's Hospital of Wisconsin 9000 W Wisconsin Avenue Milwaukee, WI 53226	7/14/2022 9:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/14/2022 9:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11019700	7/14/2022 9:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	7/14/2022 9:08 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1750482022	7/14/2022 9:08 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	7/14/2022 9:08 PM
Contacts	Authorizing Official	Insert	New Registration		Turner, Scott COO CHW and EVP CHHS Children's Hospital of Wisconsin 4142662648	7/14/2022 9:08 PM
Contacts	Primary Contact	Insert	New Registration		Ose, Megan Elizabeth Pharmacy Operations Manager Children's Wisconsin 4142665773	7/14/2022 9:08 PM
Details	Assistance Received From Date	Insert	New Registration			7/14/2022 9:08 PM
Details	Assistance Received To Date	Insert	New Registration			7/14/2022 9:08 PM
Details	Last Recertification Date	Insert	New Registration			7/14/2022 9:08 PM
Details	Grant Number	Insert	New Registration			7/14/2022 9:08 PM
Details	340B ID	Insert	New Registration			7/14/2022 9:08 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/14/2022 9:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/14/2022 9:08 PM
Details	Medicare Provider Number	Insert	New Registration		523300	7/14/2022 9:08 PM
Details	Entity Name	Insert	New Registration		CHILDRENS HOSPITAL OF WISCONSIN	7/14/2022 9:08 PM
Details	NOFO Number	Insert	New Registration			7/14/2022 9:08 PM
Details	Program Code	Insert	New Registration		PED	7/14/2022 9:08 PM
Details	Entity Subname	Insert	New Registration		Children's Hospital of Wisconsin Clinics Inc / Kenosha Clinic Orthopedics (CC9348)	7/14/2022 9:08 PM
Dates	Participating Approval Date	Insert	New Registration			7/14/2022 9:08 PM
Details	State	Insert	New Registration		Pending	7/14/2022 9:08 PM
Dates	Registration Date	Insert	New Registration		7/14/2022 9:08:47 PM	7/14/2022 9:08 PM
Dates	Signed By Date	Insert	New Registration			7/14/2022 9:08 PM
Dates	Start Date	Insert	New Registration			7/14/2022 9:08 PM
Terminations	Termination Comments	Insert	New Registration			7/14/2022 9:08 PM
Terminations	Termination Date	Insert	New Registration			7/14/2022 9:08 PM
Terminations	Termination Effective Date	Insert	New Registration			7/14/2022 9:08 PM
Terminations	Termination Reason	Insert	New Registration			7/14/2022 9:08 PM