NPIMap

Organization Active NPI

Children's Physician Group

Doing business as Crystal Lake Clinic

  • Pediatric Cardiology Physician
  • Crystal Lake, IL
National Provider Identifier
1124362306
Registry record updated Nov 12, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Cardiology PhysicianTaxonomy code 2080P0202X
Legal business name
CHILDREN'S PHYSICIAN GROUP
Doing business as
Crystal Lake Clinic
Practice address
360 Station Dr
Crystal Lake, IL 60014-7978
Phone
(815) 338-6600
Fax
(815) 477-9826
NPI assigned
Nov 12, 2012
Organization subpart
Yes
Parent organization
CHILDREN'S PHYSICIAN GROUPAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 12, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Smriti Khare, MD
Title
President, Children's Physician GRP
Phone
(414) 266-7615

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Cardiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2080P0202X Primary

Addresses

Primary practice location

360 Station Dr
Crystal Lake, IL 60014-7978

Mailing address

9000 W Wisconsin Ave
Ms 958
Milwaukee, WI 53226-4874
Phone (414) 266-7615

Other names 1

  • Crystal Lake Clinic Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Children's Physician GRP PC8 organizations share this tax ID, including this one
Part of
Children's Physician GRP PC

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1352678400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1352678400000",
    "number": "1124362306",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9000 W WISCONSIN AVE",
            "address_2": "MS 958",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532264874",
            "telephone_number": "414-266-7615",
            "fax_number": "414-266-6238"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "360 STATION DR",
            "city": "CRYSTAL LAKE",
            "state": "IL",
            "postal_code": "600147978",
            "telephone_number": "815-338-6600",
            "fax_number": "815-477-9826"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHILDREN'S PHYSICIAN GROUP",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHILDREN'S PHYSICIAN GROUP",
        "enumeration_date": "2012-11-12",
        "last_updated": "2012-11-12",
        "status": "A",
        "authorized_official_last_name": "KHARE",
        "authorized_official_first_name": "SMRITI",
        "authorized_official_title_or_position": "PRESIDENT, CHILDREN'S PHYSICIAN GRP",
        "authorized_official_telephone_number": "414-266-7615",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2080P0202X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics, Pediatric Cardiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Crystal Lake Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Crystal Lake, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.