=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790971026
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARISA AGUILA-MANALO, M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2007
-----------------------------------------------------
Last Update Date | 09/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7447 W TALCOTT AVE SUITE 312
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60631-3745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-467-9925
-----------------------------------------------------
Fax | 773-467-9938
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7447 W TALCOTT AVE SUITE 312
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60631-3745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-467-9925
-----------------------------------------------------
Fax | 773-467-9938
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARISA AGUILA-MANALO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-467-9925
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------