Provider Demographics
NPI:1619076353
Name:MANNHEIMER, JACK (MD, PC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:MANNHEIMER
Suffix:
Gender:M
Credentials:MD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N LEWIS RUN RD STE 129
Mailing Address - Street 2:
Mailing Address - City:WEST MIFFLIN
Mailing Address - State:PA
Mailing Address - Zip Code:15122-3058
Mailing Address - Country:US
Mailing Address - Phone:412-469-8220
Mailing Address - Fax:412-469-9365
Practice Address - Street 1:500 N LEWIS RUN RD STE 129
Practice Address - Street 2:
Practice Address - City:WEST MIFFLIN
Practice Address - State:PA
Practice Address - Zip Code:15122-3058
Practice Address - Country:US
Practice Address - Phone:412-469-8220
Practice Address - Fax:412-469-9365
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD009462E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0553217Medicaid
PA803622OtherMEDICARE GROUP NUMBER
PA0553217Medicaid
017791Medicare ID - Type Unspecified