MEDICARE: MARY MANIS M.S. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	J1974	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P00166344	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	127101	OTHER	TX	SUPERIOR
3	0011KW	OTHER	TX	BLUECROSS BLUESHIELD
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457352288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY MANIS M.S. M.D.

Provider Business Mailing Address
First Line	:	RUSK STATE HOSPITAL
Second Line	:	1601 NORTH DICKINSON DRIVE
City	:	RUSK
State	:	TX
Zip	:	75785
Country	:	US
Telephone Number	:	903-683-7436
Fax Number	:	903-683-7302

Provider Business Practice Location Address
First Line	:	RUSK STATE HOSPITAL
Second Line	:	1601 NORTH DICKINSON DRIVE
City	:	RUSK
State	:	TX
Zip	:	75785
Country	:	US
Telephone Number	:	903-683-7436
Fax Number	:	903-683-7302

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	06/23/2010

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Directions to “ MARY MANIS M.S. M.D.” Practice Location

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