1760567572 NPI number — GARY NEIL MANN MD

Table of content: GARY NEIL MANN MD (NPI 1760567572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760567572 NPI number — GARY NEIL MANN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANN
Provider First Name:
GARY
Provider Middle Name:
NEIL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1760567572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
571 SAINT JOSEPHS BLVD FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMIRA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14901-3230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-271-2050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 IVY ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
ELMIRA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14905-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-737-7780
Provider Business Practice Location Address Fax Number:
607-737-7788
Provider Enumeration Date:
10/27/2006

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: 208600000X , with the licence number:  MD00038838 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: Q5859 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086X0206X , with the licence number: MD00038838 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086X0206X , with the licence number: Q5859 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 286574 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1760567572 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 265110 . This is a "INTERNAL ID-MOTOR VEHICLE ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 04588487 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 349029401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0231489 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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