Basic Information
| Provider Information | |||||||||
| NPI: | 1093997975 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANEVICH | ||||||||
| FirstName: | ILYA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 PATERSON ST | ||||||||
| Address2: | SUITE 3100 | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322357827 | ||||||||
| FaxNumber: | 7322356131 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 ROUTE 72 W | ||||||||
| Address2: | |||||||||
| City: | MANAHAWKIN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080502412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099788900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2007 | ||||||||
| LastUpdateDate: | 01/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MA08285400 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | P00644610 | 01 | NJ | RR MCR PTAN | OTHER | 0153362 | 05 | NJ | MEDICAID |