Basic Information
| Provider Information | |||||||||
| NPI: | 1760567572 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | NEIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 IVY ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149051627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077377780 | ||||||||
| FaxNumber: | 6077377788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 02/18/2017 | ||||||||
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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 | 208600000X | MD00038838 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | Q5859 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | MD00038838 | WA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086X0206X | Q5859 | TX | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | 286574 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1760567572 | 05 | WA | MEDICAID | 265110 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 04588487 | 05 | NY | MEDICAID | 349029401 | 05 | TX | MEDICAID | 0231489 | 01 | WA | L&I | OTHER |