Provider Demographics
NPI:1477189959
Name:MANTILLA SURGICAL SC
Entity Type:Organization
Organization Name:MANTILLA SURGICAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-927-5299
Mailing Address - Street 1:21200 S LAGRANGE RD STE 322
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2003
Mailing Address - Country:US
Mailing Address - Phone:844-346-8686
Mailing Address - Fax:844-427-2845
Practice Address - Street 1:42 GALE AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-2010
Practice Address - Country:US
Practice Address - Phone:312-927-5299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty