Provider Demographics
NPI:1174645063
Name:MANALAC, TYRONE CHRISTOPHER A (MD)
Entity Type:Individual
Prefix:DR
First Name:TYRONE CHRISTOPHER
Middle Name:A
Last Name:MANALAC
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:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:812-375-3477
Practice Address - Street 1:2400 17TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5351
Practice Address - Country:US
Practice Address - Phone:812-376-5974
Practice Address - Fax:812-375-3203
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066591A207R00000X, 208M00000X
IN0166591A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200969260OtherC2MEDICAID
106909OtherC2SIHO
IN000000983474OtherANTHEM PIN
IN200969260OtherC2MEDICAID
000000621513OtherC2BCBS
257160EOtherC2MEDICARE
IN200969260OtherC2MEDICAID