Healthcare Provider Details

I. General information

NPI: 1851564272
Provider Name (Legal Business Name): GREGORIO MANABAT, MD MARISSA BATAYOLA, MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 W REYNOLDS ST SUITE C
PONTIAC IL
61764-9779
US

IV. Provider business mailing address

1504 W REYNOLDS ST SUITE C
PONTIAC IL
61764-9779
US

V. Phone/Fax

Practice location:
  • Phone: 815-842-2893
  • Fax: 815-844-5960
Mailing address:
  • Phone: 815-842-2893
  • Fax: 815-844-5960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: BRENDA L COLLINS
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-842-2893