Healthcare Provider Details

I. General information

NPI: 1619127024
Provider Name (Legal Business Name): MANASI REVANKAR D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 ROSEBERRY ST
PHILLIPSBURG NJ
08865-1690
US

IV. Provider business mailing address

801 OSTRUM ST ST. LUKE'S ENROLLMENT CENTER
BETHLEHEM PA
18015
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-6643
  • Fax: 484-526-4658
Mailing address:
  • Phone: 484-526-8046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB09074300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number262304
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: