1609861202 NPI number — DR. KATHLEEN E MINNICK MD

Table of content: DR. KATHLEEN E MINNICK MD (NPI 1609861202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609861202 NPI number — DR. KATHLEEN E MINNICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MINNICK
Provider First Name:
KATHLEEN
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609861202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 CLINT MOORE RD STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33487-5716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-488-1801
Provider Business Practice Location Address Fax Number:
561-451-1480
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  ME 78137 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1092080 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P971167 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 46572 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 8877 . This is a "DIMENSION" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P1035432 . This is a "FREEDOM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1023956 . This is a "CAREPLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 256694000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4586865 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 259940 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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