Basic Information
| Provider Information | |||||||||
| NPI: | 1205905106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANZELLI | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 426 S ALABAMA ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462253301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175286804 | ||||||||
| FaxNumber: | 3175282748 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 S ALABAMA ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462253301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175286804 | ||||||||
| FaxNumber: | 3175282748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05006219A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200848350C | 05 | IN | MEDICAID | 000000507113 | 01 | IN | ANTHEM/BCBS PIN | OTHER | 200469550 | 05 | IN | MEDICAID |