Healthcare Provider Details

I. General information

NPI: 1801913090
Provider Name (Legal Business Name): ALEXIS HUNT MANCHIO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

PO BOX 100
ROYAL OAK MI
48068-0100
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4811
  • Fax:
Mailing address:
  • Phone: 248-849-3137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301088049
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301088049
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number54506
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: