Provider Demographics
NPI:1710936497
Name:MANNESS, WAYNE KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:KENNETH
Last Name:MANNESS
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 1:111 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1853
Mailing Address - Country:US
Mailing Address - Phone:309-740-4272
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0914
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012423872085R0202X
OH35.0910902085R0202X
MDD006611902085R0202X
NJ25MA067277002085R0202X
PAMD057715L2085R0202X
IL036-0998162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099816Medicaid
IL212545OtherGROUP PTAN
IL202926OtherGROUP PTAN
ILG75976Medicare UPIN
IL036099816Medicaid
ILK22471Medicare PIN
ILL79954Medicare PIN
ILCH0689Medicare PIN
IL591180Medicare PIN
IL212545OtherGROUP PTAN
IL202926OtherGROUP PTAN
IL300113062Medicare PIN