Basic Information
| Provider Information | |||||||||
| NPI: | 1669836037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAI | ||||||||
| FirstName: | MANNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 223 WILMINGTON W CHESTER PIKE STE 214 | ||||||||
| Address2: | |||||||||
| City: | CHADDS FORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193179007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443657246 | ||||||||
| FaxNumber: | 6103617956 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 SILVERSIDE RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198091768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443657246 | ||||||||
| FaxNumber: | 8445160080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | C20023945 | DE | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208VP0000X | C2-0023945 | DE | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 250657049 | 05 | DE | MEDICAID | 587195600 | 05 | MD | MEDICAID |