Provider Demographics
NPI:1689689010
Name:MANNING, EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MANNING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11407
Mailing Address - Street 2:DEPT # 2130
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2130
Mailing Address - Country:US
Mailing Address - Phone:601-984-5500
Mailing Address - Fax:601-984-5499
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPT OF NEUROLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5500
Practice Address - Fax:601-984-5499
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25-324103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1676608Medicaid
MS0110219Medicaid
MS680000065Medicare ID - Type Unspecified
MS302I687026Medicare PIN
MS0110219Medicaid