Basic Information
Provider Information | |||||||||
NPI: | 1174645063 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANALAC | ||||||||
FirstName: | TYRONE CHRISTOPHER | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 411 PLAZA DRIVE, SUITE H | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | IN | ||||||||
PostalCode: | 47201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123765974 | ||||||||
FaxNumber: | 8123753203 | ||||||||
Practice Location | |||||||||
Address1: | 2400 17TH ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | IN | ||||||||
PostalCode: | 472015351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123765974 | ||||||||
FaxNumber: | 8123753203 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2007 | ||||||||
LastUpdateDate: | 01/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01066591A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 0166591A | IN | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 1336510098 | 01 | IN | GROUP NPI | OTHER | 106909 | 01 |   | C2SIHO | OTHER | 000000983474 | 01 | IN | ANTHEM PIN | OTHER | 200969260 | 01 | IN | C2MEDICAID | OTHER | 000000621513 | 01 |   | C2BCBS | OTHER | 257160E | 01 |   | C2MEDICARE | OTHER |