Provider Demographics
NPI:1619147303
Name:GEORGE T MANITSAS MD LLC
Entity type:Organization
Organization Name:GEORGE T MANITSAS MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:T
Authorized Official - Last Name:MANITSAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-863-5592
Mailing Address - Street 1:1380 NW WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-6310
Mailing Address - Country:US
Mailing Address - Phone:513-863-5592
Mailing Address - Fax:513-863-6772
Practice Address - Street 1:1380 NW WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-6310
Practice Address - Country:US
Practice Address - Phone:513-863-5592
Practice Address - Fax:513-863-6772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35031371207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0165673Medicaid
OH0165673Medicaid