Provider Demographics
NPI:1790971026
Name:MARISA AGUILA-MANALO, M.D.
Entity Type:Organization
Organization Name:MARISA AGUILA-MANALO, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUILA-MANALO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-467-9925
Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:773-467-9925
Mailing Address - Fax:773-467-9938
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-467-9925
Practice Address - Fax:773-467-9938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF35270Medicare UPIN
IL201212Medicare PIN