Healthcare Provider Details

I. General information

NPI: 1245255934
Provider Name (Legal Business Name): MAUREEN A BOYLE-MANGANARO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 RIDGE ST STE 312
COUNCIL BLUFFS IA
51503-4643
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 712-396-7880
  • Fax: 712-396-7885
Mailing address:
  • Phone: 402-354-2100
  • Fax: 402-354-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number28036
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2001005627
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberMD-43345
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: