MEDICARE: DR. BARRY ELLIS MANTELL 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	2085R0202X	Diagnostic Radiology Physician	G40977	CA

General Provider Information

NPI Number	:	1154409019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BARRY ELLIS MANTELL M.D.

Provider Business Mailing Address
First Line	:	420 W SANTA ELENA RD
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-2926
Country	:	US
Telephone Number	:	760-464-3892
Fax Number	:	760-323-7259

Provider Business Practice Location Address
First Line	:	420 W SANTA ELENA RD
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-2926
Country	:	US
Telephone Number	:	760-464-3892
Fax Number	:	760-323-7259

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	04/20/2009

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