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PED523300-02 CHILDREN'S HOSPITAL OF WISCONSIN, INC. (Terminated)
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Main Details
Name
CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Subdivision Name
CHILDREN'S HOSPITAL OF WISCONSIN SPECIALTY CLINICS (AKA:SPECIALTY CLINICS AT SINAI-SAMARITAN-DTHC, CHILD PROTECTION, DENTAL CTR)
Type
Children's Hospital
Rural
No
340B ID
PED523300-02
Medicare Provider Number
523300
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
3/10/2010
Participating Start Date
4/1/2010
Participating Approval Date
3/11/2010
Last Recertification Date
8/13/2015
Termination Date
Termination Reason
10/1/2016
Site closure
Contacts
Authorizing Official
Children's Hospital of Wisconsin
Scott Turner, COO CHW and EVP CHHS
(414) 266-2648
Primary Contact
Marc H. Gorelick, EXECUTIVE VICE PRESIDENT
(414) 266-2648
Addresses
Street Address
1020 NORTH 12TH STREET
MILWAUKEE, WI 53223
Billing Address
CHILDREN'S HOSPITAL OF WISCONSIN, INC.
9000 W. WISCONSIN AVENUE
MAIL STATION 730
MILWAUKEE, WI 53226
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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