Healthcare Provider Details

I. General information

NPI: 1598848194
Provider Name (Legal Business Name): MANISH MATHUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 N EDWARDSVILLE ST
STAUNTON IL
62088-1334
US

IV. Provider business mailing address

444 N EDWARDSVILLE ST
STAUNTON IL
62088-1334
US

V. Phone/Fax

Practice location:
  • Phone: 618-635-3800
  • Fax: 618-635-3952
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: