Provider Demographics
NPI:1962470336
Name:MCCOLLEY, SUSANNA ANTONIA (MD)
Entity type:Individual
Prefix:MRS
First Name:SUSANNA
Middle Name:ANTONIA
Last Name:MCCOLLEY
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 1:1137 WEST MONTANA
Mailing Address - Street 2:
Mailing Address - City:CHGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2220
Mailing Address - Country:US
Mailing Address - Phone:773-348-0979
Mailing Address - Fax:
Practice Address - Street 1:2300 CHILDRENS PLAZA
Practice Address - Street 2:#43
Practice Address - City:CHGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-880-8104
Practice Address - Fax:773-880-6300
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360893842080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089384Medicaid
ILL35996Medicare ID - Type Unspecified
IL036089384Medicaid