Basic Information
| Provider Information | |||||||||
| NPI: | 1629091251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANCINI | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10400 SOUTHWEST HWY | ||||||||
| Address2: | LL | ||||||||
| City: | CHICAGO RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604151367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085817308 | ||||||||
| FaxNumber: | 7082744027 | ||||||||
| Practice Location | |||||||||
| Address1: | 15234 S HARLEM AVE | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604624330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086334544 | ||||||||
| FaxNumber: | 7086140607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-115425 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208800000X | 036-115425 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | P00401392 | 01 | MEDICARE RAILROAD | OTHER | 036-115425 | 01 | IL | MEDICAL LICENSE | OTHER | 36-115425 | 05 | IL | MEDICAID | IL3265 | 01 | GROUP PTAN | OTHER |