Provider Demographics
NPI:1669444683
Name:MANNO, EDWARD M (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:MANNO
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 1:625 N MICHIGAN AVE STE 1150
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3110
Mailing Address - Country:US
Mailing Address - Phone:312-503-6192
Mailing Address - Fax:
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361412072084V0102X, 2084A2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN236933800Medicaid
MN236933800Medicaid
G18050Medicare UPIN
MN130000946Medicare ID - Type Unspecified