Provider Demographics
NPI:1720052830
Name:MANERA, RICARCHITO (MD)
Entity Type:Individual
Prefix:
First Name:RICARCHITO
Middle Name:
Last Name:MANERA
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 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4440 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-4094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL361000662080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36100066Medicaid
IL554440Medicare ID - Type Unspecified
G40103Medicare UPIN