Healthcare Provider Details

I. General information

NPI: 1568459998
Provider Name (Legal Business Name): ELWYN C MANTEI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3123 SHORE DR STE 102
MARINETTE WI
54143-4287
US

IV. Provider business mailing address

3123 SHORE DR STE 102
MARINETTE WI
54143-4287
US

V. Phone/Fax

Practice location:
  • Phone: 715-732-2299
  • Fax: 715-732-2419
Mailing address:
  • Phone: 715-732-2299
  • Fax: 715-732-2419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number22450020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: