Provider Demographics
NPI:1396711503
Name:MESIROW, MANUEL S (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:S
Last Name:MESIROW
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 1:18425 W WEST CREEK DR
Mailing Address - Street 2:STE F
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6767
Mailing Address - Country:US
Mailing Address - Phone:708-444-8300
Mailing Address - Fax:708-444-8301
Practice Address - Street 1:18425 W WEST CREEK DR
Practice Address - Street 2:STE F
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6767
Practice Address - Country:US
Practice Address - Phone:708-444-8300
Practice Address - Fax:708-444-8301
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054932174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC25146Medicare UPIN
ILK14035Medicare PIN