Provider Demographics
NPI:1861501637
Name:MANNING, THOMAS CRELLIN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:CRELLIN
Last Name:MANNING
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 1:6140 W CURTISIAN AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8907
Mailing Address - Country:US
Mailing Address - Phone:208-327-5600
Mailing Address - Fax:208-327-5602
Practice Address - Street 1:6140 W CURTISIAN AVE STE 400
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8907
Practice Address - Country:US
Practice Address - Phone:208-327-5600
Practice Address - Fax:208-327-5602
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9928207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
8944944OtherCRIMES VICTIMS
ID1861501637Medicaid
ID20140OtherBLUE CROSS OF IDAHO
006154OtherOMAP
ID0222532OtherWA DEPT OF LABOR
ID100001035500OtherREGENCE BLUESHIELD OF IDAHO
ID000010162796OtherBLUE SHIELD OF ID
ID6134900001Medicare NSC
006154OtherOMAP