Provider Demographics
NPI:1861792103
Name:MANUBAY MEDICAL CLINIC MD INC
Entity type:Organization
Organization Name:MANUBAY MEDICAL CLINIC MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESITA
Authorized Official - Middle Name:I
Authorized Official - Last Name:MANUBAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-888-9823
Mailing Address - Street 1:1312 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2526
Mailing Address - Country:US
Mailing Address - Phone:573-888-1224
Mailing Address - Fax:573-888-9823
Practice Address - Street 1:1312 1ST ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2526
Practice Address - Country:US
Practice Address - Phone:573-888-1224
Practice Address - Fax:573-888-9823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMOMDR6794208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR107995001Medicaid
MO200363505Medicaid
9798Medicare UPIN
000009798Medicare PIN