1366428229 NPI number — DR. STEPHEN MINNIS M.D.

Table of content: DR. STEPHEN MINNIS M.D. (NPI 1366428229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366428229 NPI number — DR. STEPHEN MINNIS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MINNIS
Provider First Name:
STEPHEN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1366428229
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
860 BETHESDA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZANESVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43701-1800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-454-4651
Provider Business Mailing Address Fax Number:
740-454-4653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
751 FOREST AVE
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
ZANESVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43701-2868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-454-8502
Provider Business Practice Location Address Fax Number:
740-454-8641
Provider Enumeration Date:
12/21/2005

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: 208000000X , with the licence number:  35054785M , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000177369 . This is a "UNISON PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0701244 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000019439 . This is a "ANTHEM PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0989499 . This is a "GROUP MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1204559 . This is a "UHC PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 311413469027 . This is a "CARESOURCE PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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