Provider Demographics
NPI:1821141037
Name:MANNIS, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MANNIS
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 1:3009 N BALLAS RD
Mailing Address - Street 2:SUITE 105B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2322
Mailing Address - Country:US
Mailing Address - Phone:314-432-2323
Mailing Address - Fax:314-432-5328
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:SUITE 105B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-432-2323
Practice Address - Fax:314-432-5328
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO32416174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0900023OtherUNITED HEALTHCARE
MO122201OtherHEALTHLINK
MOA12809OtherMERCY HEALTH PLANS
MO3567OtherGROUP HEALTH PLAN
MO3124702001OtherCIGNA
MO4210117OtherAETNA
MOP00195673OtherRR MEDICARE
43092556563080A001OtherWPS TRICARE
MO22185OtherBCBS OF MO (ANTHEM)
A12809Medicare UPIN