Provider Demographics
NPI:1598712218
Name:ASCANO, MANUEL R SR (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:R
Last Name:ASCANO
Suffix:SR
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 1:530 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-3901
Mailing Address - Country:US
Mailing Address - Phone:815-875-2811
Mailing Address - Fax:
Practice Address - Street 1:535 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2537
Practice Address - Country:US
Practice Address - Phone:815-875-4531
Practice Address - Fax:815-876-2118
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073015207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00219992OtherRAILROAD MEDICARE
IL036073015Medicaid
IL0360730154Medicaid
ILP00219992OtherRAILROAD MCR
ILK12447Medicare PIN
IL0360730154Medicaid
ILC54857Medicare UPIN