MEDICARE: DR. JEAN MARIE MANCINI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	038379	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	4091342	OTHER	BCTN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013914308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEAN MARIE MANCINI M.D.

Provider Business Mailing Address
First Line	:	PO BOX 9
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37662-0009
Country	:	US
Telephone Number	:	423-857-2066
Fax Number	:	423-857-2070

Provider Business Practice Location Address
First Line	:	1 MEDICAL PARK BLVD
Second Line	:	STE 450W
City	:	BRISTOL
State	:	TN
Zip	:	37620-7430
Country	:	US
Telephone Number	:	423-968-3713
Fax Number	:	423-986-7352

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	06/11/2014

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