Basic Information
| Provider Information | |||||||||
| NPI: | 1306909148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 379 | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604620379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084609836 | ||||||||
| FaxNumber: | 7084601117 | ||||||||
| Practice Location | |||||||||
| Address1: | 5850 W 111TH ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084252466 | ||||||||
| FaxNumber: | 7084254796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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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 | 207W00000X | 036043622 | IL | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 036043622 | 05 | IL | MEDICAID |