Provider Demographics
NPI:1487644175
Name:MANN, CAROL J (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:J
Last Name:MANN
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:6913 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8039
Practice Address - Country:US
Practice Address - Phone:574-647-1500
Practice Address - Fax:574-243-4306
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044166A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100373480Medicaid
IN000000796154OtherBCBS
IN000000970918OtherBCBS MEDPOINT
IN000000785289OtherBCBS
IN100373480Medicaid
IN000000785289OtherBCBS
IN236040149Medicare PIN
IN000000970918OtherBCBS MEDPOINT
ININ1133015Medicare PIN