Provider Demographics
NPI:1821065764
Name:MANDIS, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:MANDIS
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 1:6810 STATE ROUTE 162 BOX 215
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-391-6405
Mailing Address - Fax:618-288-4088
Practice Address - Street 1:2236 VADALABENE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5844
Practice Address - Country:US
Practice Address - Phone:618-288-6136
Practice Address - Fax:618-288-6143
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112094207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I23797OtherMERCY
IL036112094Medicaid
IL036112094-3Medicaid
P00265571OtherMEDICARE RAILROAD
IL036112094-5Medicaid
MO1821065764Medicaid
IL06032146OtherBLUE CROSS ILLINOIS
202790173OtherTRICARE
7496677OtherAETNA
241366OtherGHP
701184OtherHEALTHLINK
MO199147OtherBLUE SHIELD MO
IL036112094-5Medicaid
I23797Medicare UPIN
MO1821065764Medicaid