Healthcare Provider Details

I. General information

NPI: 1477189959
Provider Name (Legal Business Name): MANTILLA SURGICAL SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 GALE AVE
RIVER FOREST IL
60305-2010
US

IV. Provider business mailing address

21200 S LAGRANGE RD STE 322
FRANKFORT IL
60423-2003
US

V. Phone/Fax

Practice location:
  • Phone: 312-927-5299
  • Fax:
Mailing address:
  • Phone: 844-346-8686
  • Fax: 844-427-2845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NATHALIE MANTILLA
Title or Position: PRESIDENT
Credential: MD
Phone: 312-927-5299