Provider Demographics
NPI:1982731444
Name:MANZER FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:MANZER FAMILY MEDICINE, LLC
Other - Org Name:JONATHAN MANZER
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:MANZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-358-4811
Mailing Address - Street 1:3071 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-7851
Mailing Address - Country:US
Mailing Address - Phone:417-358-4811
Mailing Address - Fax:
Practice Address - Street 1:3071 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-7851
Practice Address - Country:US
Practice Address - Phone:417-358-4811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209288406Medicaid
MOI08912Medicare UPIN
MO000014211Medicare PIN