Provider Demographics
NPI:1821096470
Name:TANNA, MANISH (MD)
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:
Last Name:TANNA
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 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:
Practice Address - Street 1:601 W GOLF RD STE 105
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-4276
Practice Address - Country:US
Practice Address - Phone:847-439-8780
Practice Address - Fax:847-439-8940
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096147207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1616108OtherBCBS
IL036096147Medicaid
IL1616108OtherBCBS
ILL79124Medicare PIN
IL922820Medicare ID - Type UnspecifiedGROUP NUMBER
IL575480Medicare ID - Type UnspecifiedGROUP NUMBER
IL036096147Medicaid
ILH19129Medicare UPIN
ILK01508Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER