Basic Information
| Provider Information | |||||||||
| NPI: | 1194855460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINEO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 ALCONA AVE | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142262201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168341193 | ||||||||
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| Practice Location | |||||||||
| Address1: | 127 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140201631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853436030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 03/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 238200 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00028022001 | 01 | NY | UNIVERA HEALTHCARE | OTHER | 000529157001 | 01 | NY | BLUE CROSS | OTHER | 070412000094 | 01 | NY | FIDELIS CARE NY | OTHER | 3914237 | 01 | NY | INDEPENDENT HEALTH | OTHER | 02860108 | 05 | NY | MEDICAID |