MEDICARE: JORGE MANTILLA SA-C

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	246ZC0007X	Surgical Assistant	19-180	TX
2	363AS0400X	Surgical Physician Assistant	238.000655	IL

General Provider Information

NPI Number	:	1962065516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE MANTILLA SA-C

Provider Business Mailing Address
First Line	:	5540 N KIMBALL AVE APT 3E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4674
Country	:	US
Telephone Number	:	312-983-0540
Fax Number	:

Provider Business Practice Location Address
First Line	:	5540 N KIMBALL AVE APT 3E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4674
Country	:	US
Telephone Number	:	312-983-0540
Fax Number	:

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

Provider Enumeration Date	:	04/18/2019
Last Update Date	:	02/11/2020

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Directions to “ JORGE MANTILLA SA-C” Practice Location

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