Healthcare Provider Details

I. General information

NPI: 1851340970
Provider Name (Legal Business Name): MARC N MANGER M.D., PLC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10645 N TATUM BLVD SUITE 200, PMB 611
PHOENIX AZ
85028-3068
US

IV. Provider business mailing address

10645 N TATUM BLVD SUITE 200, PMB 611
PHOENIX AZ
85028-3068
US

V. Phone/Fax

Practice location:
  • Phone: 480-111-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number24242
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number24242
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24242
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number24242
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number24242
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number24242
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number24242
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number24242
License Number StateAZ
# 9
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number24242
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: