Provider Demographics
NPI:1740274851
Name:SUPPLE, MARGARET ANNE (MD)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:ANNE
Last Name:SUPPLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:ANNE
Other - Last Name:SUPPLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3800 HIGHLAND AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1557
Mailing Address - Country:US
Mailing Address - Phone:630-969-8090
Mailing Address - Fax:630-969-8087
Practice Address - Street 1:3800 HIGHLAND AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1557
Practice Address - Country:US
Practice Address - Phone:630-969-8090
Practice Address - Fax:630-969-8087
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046360208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036046360Medicaid