Basic Information
| Provider Information | |||||||||
| NPI: | 1821065764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANDIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6810 STATE ROUTE 162 BOX 215 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183916405 | ||||||||
| FaxNumber: | 6182884088 | ||||||||
| Practice Location | |||||||||
| Address1: | 2236 VADALABENE DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182886136 | ||||||||
| FaxNumber: | 6182886143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036112094 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 036112094 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | I23797 | 01 | MERCY | OTHER | 036112094 | 05 | IL | MEDICAID | 036112094-3 | 05 | IL | MEDICAID | P00265571 | 01 | MEDICARE RAILROAD | OTHER | 036112094-5 | 05 | IL | MEDICAID | 1821065764 | 05 | MO | MEDICAID | 06032146 | 01 | IL | BLUE CROSS ILLINOIS | OTHER | 202790173 | 01 | TRICARE | OTHER | 7496677 | 01 | AETNA | OTHER | 241366 | 01 | GHP | OTHER | 701184 | 01 | HEALTHLINK | OTHER | 199147 | 01 | MO | BLUE SHIELD MO | OTHER |