Provider Demographics
NPI:1972782662
Name:CLOVIS E. MANLEY, MD LLC
Entity type:Organization
Organization Name:CLOVIS E. MANLEY, MD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLOVIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:MANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-490-9462
Mailing Address - Street 1:4943 ROSEBUD LN
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-9226
Mailing Address - Country:US
Mailing Address - Phone:812-471-8195
Mailing Address - Fax:812-490-1060
Practice Address - Street 1:4943 ROSEBUD LN
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-9226
Practice Address - Country:US
Practice Address - Phone:812-471-8195
Practice Address - Fax:812-490-1060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036788207Q00000X
IN71001387A207Q00000X
IN71001874A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN211850Medicare PIN
IND95035Medicare UPIN
IN211850AMedicare PIN
INQ00009Medicare UPIN
IN211850BMedicare PIN
IN4628860001Medicare NSC
IN191640Medicare PIN