Healthcare Provider Details

I. General information

NPI: 1467803098
Provider Name (Legal Business Name): MANASI SUHAS HULYALKAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 SMIZER MILL RD STE 108
FENTON MO
63026-3483
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 636-717-1340
  • Fax:
Mailing address:
  • Phone: 636-717-1340
  • Fax: 636-717-1344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036148207
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.068917
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025029192
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License Number036148207
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: