Provider Demographics
NPI:1174619753
Name:MANOLIS, EVAN T (MD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:T
Last Name:MANOLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8760 W 159TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-5395
Mailing Address - Country:US
Mailing Address - Phone:708-873-9600
Mailing Address - Fax:708-873-9607
Practice Address - Street 1:8760 W 159TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-5395
Practice Address - Country:US
Practice Address - Phone:708-873-9600
Practice Address - Fax:708-873-9607
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0931682086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093168Medicaid
ILG74934Medicare UPIN
IL209502Medicare PIN