Provider Demographics
NPI:1093997975
Name:MANEVICH, ILYA (MD)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:MANEVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PATERSON ST
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1962
Mailing Address - Country:US
Mailing Address - Phone:732-235-7827
Mailing Address - Fax:732-235-6131
Practice Address - Street 1:1140 ROUTE 72 W
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2412
Practice Address - Country:US
Practice Address - Phone:609-978-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08285400207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00644610OtherRR MCR PTAN
NJ0153362Medicaid
NJ125382A01Medicare PIN
NJ125382CDYMedicare PIN
NJ125382CDZMedicare PIN