Healthcare Provider Details

I. General information

NPI: 1760068456
Provider Name (Legal Business Name): MADELINE SUPPIGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 W IRONWOOD DR STE 306
COEUR D ALENE ID
83814-2668
US

IV. Provider business mailing address

6420 CLAYTON RD
SAINT LOUIS MO
63117-1811
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-4970
  • Fax: 208-625-4991
Mailing address:
  • Phone: 314-781-4772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3171569
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: