Basic Information
| Provider Information | |||||||||
| NPI: | 1861490310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANGANIELLO | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1388 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187040379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702888881 | ||||||||
| FaxNumber: | 5702888065 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DURYEA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186421325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704571110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD037791L | PA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0013919460001 | 05 | PA | MEDICAID | 001216 | 01 | PA | FIRST PRIORITY HEALTH | OTHER | 024946 | 01 | PA | FIRST PRIORITY LIFE INS C | OTHER | 020338000 | 01 | PA | BLACK LUNG | OTHER | 024946 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 14821 E222 | 01 | PA | GEISINGER HEALTH PLAN | OTHER |