Provider Demographics
NPI:1467611939
Name:ELIZABETH E MANNICK MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ELIZABETH E MANNICK MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:MANNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-877-2424
Mailing Address - Street 1:1630B PIIHOLO RD
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-7244
Mailing Address - Country:US
Mailing Address - Phone:808-283-3330
Mailing Address - Fax:808-877-6464
Practice Address - Street 1:39 KAMEHAMEHA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2263
Practice Address - Country:US
Practice Address - Phone:808-877-2424
Practice Address - Fax:808-877-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIHI 13829207RG0100X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1306879747OtherNPPES
1306879747OtherNPPES