Provider Demographics
NPI:1760463111
Name:COLLINS, MARY B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:B
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:5057 SHORELINE RD
Practice Address - Street 2:
Practice Address - City:LAKE BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-1700
Practice Address - Country:US
Practice Address - Phone:847-381-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064956208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064956Medicaid