Provider Demographics
NPI:1831129477
Name:MANCINI, PETER II (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MANCINI
Suffix:II
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 1:19768 BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-3911
Mailing Address - Country:US
Mailing Address - Phone:313-418-6001
Mailing Address - Fax:248-792-9159
Practice Address - Street 1:2881 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3475
Practice Address - Country:US
Practice Address - Phone:313-562-3232
Practice Address - Fax:313-563-3330
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061557207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
060064248OtherMEDICARE RR
MI4308863Medicaid
MIP112550OtherBLUECARENETWORK
MI0Q26305005OtherBLUECROSSBLUESHIELD OF MI
MIF34995Medicare UPIN
MI4308863Medicaid