Provider Demographics
NPI:1760703128
Name:WALLACH, MARGARET MARY (PA- C)
Entity Type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:MARY
Last Name:WALLACH
Suffix:
Gender:F
Credentials:PA- C
Other - Prefix:MS
Other - First Name:MARGARET
Other - Middle Name:TURK
Other - Last Name:WALLACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:15300 WEST AVE
Mailing Address - Street 2:SUITE 200 EAST
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:SUITE 200 EAST
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:630-347-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.000299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant