Provider Demographics
NPI:1639147002
Name:MANCINI, ANTHONY J (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:MANCINI
Suffix:
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 1:2300 CHILDRENS PLAZA
Mailing Address - Street 2:#107
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:312-227-6060
Mailing Address - Fax:312-227-9402
Practice Address - Street 1:2300 CHILDRENS PLAZA
Practice Address - Street 2:#107
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-327-3446
Practice Address - Fax:773-327-3448
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092834207N00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092834Medicaid
IL036092834Medicaid
ILL55670Medicare ID - Type Unspecified