Basic Information
| Provider Information | |||||||||
| NPI: | 1497843650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | MANI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012014109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472752 | ||||||||
| FaxNumber: | 4134966836 | ||||||||
| Practice Location | |||||||||
| Address1: | 27 LEWIS AVE | ||||||||
| Address2: | |||||||||
| City: | GT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012301886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135285006 | ||||||||
| FaxNumber: | 4135286743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 10/19/2011 | ||||||||
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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 | 207R00000X | 48690 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0189928 | 05 | MA | MEDICAID |