Provider Demographics
NPI:1306909148
Name:MANN, EDWARD PHILIP (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:PHILIP
Last Name:MANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 379
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-0379
Mailing Address - Country:US
Mailing Address - Phone:708-460-9836
Mailing Address - Fax:708-460-1117
Practice Address - Street 1:5850 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415
Practice Address - Country:US
Practice Address - Phone:708-425-2466
Practice Address - Fax:708-425-4796
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036043622207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036043622Medicaid
D13503Medicare UPIN
IL036043622Medicaid