Healthcare Provider Details

I. General information

NPI: 1265230916
Provider Name (Legal Business Name): MADELEINE GRACE SUBACH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12251 S 80TH AVE STE 1520
PALOS HEIGHTS IL
60463-1290
US

IV. Provider business mailing address

12251 S 80TH AVE STE 1520
PALOS HEIGHTS IL
60463-1290
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-4200
  • Fax: 708-923-4201
Mailing address:
  • Phone: 708-923-4200
  • Fax: 708-923-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011216
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: