Provider Demographics
NPI:1104805126
Name:MANAHAN, FERDINAND J (MD)
Entity type:Individual
Prefix:
First Name:FERDINAND
Middle Name:J
Last Name:MANAHAN
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 1:239 PENN AVENUE FORUM PLAZA
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503
Mailing Address - Country:US
Mailing Address - Phone:570-346-6170
Mailing Address - Fax:570-346-2575
Practice Address - Street 1:239 PENN AVENUE FORUM PLAZA
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503
Practice Address - Country:US
Practice Address - Phone:570-346-6170
Practice Address - Fax:570-346-2575
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043284E207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1165195Medicaid
505518OtherAETNA
PA0669043OtherMEDICAL ASSISTANCE
PA440302OtherFIRST PRIORITY
PA38078OtherGEISINGER HEALTH PLAN
PA440302OtherFIRST PRIORITY
E52789Medicare UPIN
036549F52Medicare ID - Type Unspecified