=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902300841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL MAX MANSTEIN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2018
-----------------------------------------------------
Last Update Date | 03/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MEDICAL DR DEPT OF
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03756-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-650-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8226 FAIRVIEW RD
-----------------------------------------------------
City | ELKINS PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19027-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-380-4405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------