Basic Information
| Provider Information | |||||||||
| NPI: | 1396749891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANEGOLD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 632958 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452632958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134519698 | ||||||||
| FaxNumber: | 5134519699 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 KIPLING AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452396600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132334100 | ||||||||
| FaxNumber: | 5137512267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 10/08/2012 | ||||||||
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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 | 207RG0100X | 35-051751 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 100010946 | 01 | OH | RAILROAD MEDICARE | OTHER | 0737920 | 05 | OH | MEDICAID |