1154346336 NPI number — CAROL MANNING MD

Table of content: CAROL MANNING MD (NPI 1154346336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154346336 NPI number — CAROL MANNING MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANNING
Provider First Name:
CAROL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

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 Information

NPI Number:
1154346336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160 PITTSFORD VICTOR RD
Provider Second Line Business Mailing Address:
D-2
Provider Business Mailing Address City Name:
PITTSFORD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14534-3825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-218-8007
Provider Business Mailing Address Fax Number:
585-218-8099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3320 N LOS COYOTES DIAGONAL
Provider Second Line Business Practice Location Address:
SUITE 120, 112 & 260
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90808-3918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-627-0903
Provider Business Practice Location Address Fax Number:
562-627-0923
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  G40306 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G403060 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G403060 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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