Provider Demographics
NPI:1750905097
Name:MANCHA, GENESIS TALIA (MD)
Entity type:Individual
Prefix:DR
First Name:GENESIS
Middle Name:TALIA
Last Name:MANCHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 W JACKSON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3227
Mailing Address - Country:US
Mailing Address - Phone:312-942-2200
Mailing Address - Fax:
Practice Address - Street 1:1645 W JACKSON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3227
Practice Address - Country:US
Practice Address - Phone:312-942-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.077066208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program