Provider Demographics
NPI:1356342745
Name:TENNILLE, MARGUERITE T (MD)
Entity type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:T
Last Name:TENNILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARGUERITE
Other - Middle Name:T
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2808 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4138
Mailing Address - Country:US
Mailing Address - Phone:336-765-9000
Mailing Address - Fax:336-765-5702
Practice Address - Street 1:2808 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4138
Practice Address - Country:US
Practice Address - Phone:336-765-9000
Practice Address - Fax:336-765-5702
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27002208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8988384Medicaid
AW 2148446OtherDEA
D01118Medicare UPIN