=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568459998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELWYN C MANTEI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2005
-----------------------------------------------------
Last Update Date | 10/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3123 SHORE DR STE 102
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-4287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-732-2299
-----------------------------------------------------
Fax | 715-732-2419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3123 SHORE DR STE 102
-----------------------------------------------------
City | MARINETTE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54143-4287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-732-2299
-----------------------------------------------------
Fax | 715-732-2419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 22450020
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------