1366576415 NPI number — DR. ELIZABETH M MANN DO

Table of content: DR. ELIZABETH M MANN DO (NPI 1366576415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366576415 NPI number — DR. ELIZABETH M MANN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANN
Provider First Name:
ELIZABETH
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORGAN
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
ELIZABETH M OTT DO
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366576415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4199 GATEWAY BLVD
Provider Second Line Business Mailing Address:
STE 2400
Provider Business Mailing Address City Name:
NEWBURGH
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47630-7972
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-858-4600
Provider Business Mailing Address Fax Number:
812-858-4601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4199 GATEWAY BLVD
Provider Second Line Business Practice Location Address:
SUITE 2400
Provider Business Practice Location Address City Name:
NEWBURGH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47630-8940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-858-4600
Provider Business Practice Location Address Fax Number:
812-858-4601
Provider Enumeration Date:
03/14/2007

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: 207V00000X , with the licence number:  02003321A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200915200 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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