Provider Demographics
NPI:1851564272
Name:GREGORIO MANABAT, MD MARISSA BATAYOLA, MD SC
Entity Type:Organization
Organization Name:GREGORIO MANABAT, MD MARISSA BATAYOLA, MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-842-2893
Mailing Address - Street 1:1504 W REYNOLDS ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9779
Mailing Address - Country:US
Mailing Address - Phone:815-842-2893
Mailing Address - Fax:815-844-5960
Practice Address - Street 1:1504 W REYNOLDS ST
Practice Address - Street 2:SUITE C
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9779
Practice Address - Country:US
Practice Address - Phone:815-842-2893
Practice Address - Fax:815-844-5960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5315070OtherBLUE CROSS BLUE SHIELD
IL963070Medicare PIN