1821065764 NPI number — DR. MICHAEL E MANDIS MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821065764 NPI number — DR. MICHAEL E MANDIS MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MANDIS

Provider First Name:

MICHAEL

Provider Middle Name:

E

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1821065764

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/31/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

6810 STATE ROUTE 162 BOX 215

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

MARYVILLE

Provider Business Mailing Address State Name:

IL

Provider Business Mailing Address Postal Code:

62062-8501

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

618-391-6405

Provider Business Mailing Address Fax Number:

618-288-4088

Provider First Line Business Practice Location Address:

2236 VADALABENE DR

Provider Second Line Business Practice Location Address:

SUITE 2

Provider Business Practice Location Address City Name:

MARYVILLE

Provider Business Practice Location Address State Name:

IL

Provider Business Practice Location Address Postal Code:

62062-5844

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

618-288-6136

Provider Business Practice Location Address Fax Number:

618-288-6143

Provider Enumeration Date:

02/28/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207P00000X , with the licence number:  036112094 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207R00000X , with the licence number: 036112094 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: I23797 . This is a "MERCY" identifier . This identifiers is of the category "OTHER".
• Identifier: 036112094 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
• Identifier: 036112094-3 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
• Identifier: P00265571 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
• Identifier: 036112094-5 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
• Identifier: 1821065764 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
• Identifier: 06032146 . This is a "BLUE CROSS ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: 202790173 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 7496677 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 241366 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
• Identifier: 701184 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
• Identifier: 199147 . This is a "BLUE SHIELD MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".