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NPI Code Detail

MEDICARE: DR. CRYSTAL VAUGHN MANSE M.D.

MEDICARE: DR. CRYSTAL VAUGHN MANSE 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
1208D00000XGeneral Practice Physician0101255760VA
2208M00000XHospitalist Physician036139867IL
3207R00000XInternal Medicine Physician036139867IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1366702870
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CRYSTAL VAUGHN MANSE M.D.
Provider Business Mailing Address
First Line : 3 SAINT ELIZABETH BLVD
Second Line :
City : O FALLON
State : IL
Zip : 62269-1281
Country : US
Telephone Number : 618-234-2120
Fax Number :
Provider Business Practice Location Address
First Line : 3 SAINT ELIZABETH BLVD STE 4000
Second Line :
City : O FALLON
State : IL
Zip : 62269-1284
Country : US
Telephone Number : 618-233-5480
Fax Number : 618-222-4792
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/18/2012
Last Update Date : 09/12/2024

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