Healthcare Provider Details

I. General information

NPI: 1760588024
Provider Name (Legal Business Name): MARY ELIZABETH MANI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD SUITE 250C
ST LOUIS MO
63131
US

IV. Provider business mailing address

180 WEIDMAN ROAD SUITE 125
ST LOUIS MO
63021
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-9199
  • Fax: 314-432-1524
Mailing address:
  • Phone: 636-207-0277
  • Fax: 636-207-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number100216
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: