Provider Demographics
NPI:1407813470
Name:MANALO, JANE GRACE MERCADO (MD)
Entity Type:Individual
Prefix:
First Name:JANE GRACE
Middle Name:MERCADO
Last Name:MANALO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-2190
Mailing Address - Country:US
Mailing Address - Phone:217-342-2066
Mailing Address - Fax:217-342-2074
Practice Address - Street 1:905 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2190
Practice Address - Country:US
Practice Address - Phone:217-342-2066
Practice Address - Fax:217-342-2074
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT84859581-1205207RH0003X
IL036122145207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT88847357001Medicaid
H38347Medicare UPIN
UT88847357001Medicaid