Provider Demographics
NPI:1376643346
Name:MANN, MICHAEL SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:MANN
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 11766
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46860-1766
Mailing Address - Country:US
Mailing Address - Phone:260-338-1104
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033792A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN138420NMedicare ID - Type Unspecified
IN178650FMedicare ID - Type Unspecified
B06349Medicare UPIN
IN295910EMedicare ID - Type Unspecified