Basic Information
| Provider Information | |||||||||
| NPI: | 1306811765 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINERT | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | QUENTIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C. O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 215 | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481390215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102316905 | ||||||||
| FaxNumber: | 8102316906 | ||||||||
| Practice Location | |||||||||
| Address1: | 10020 PROFESSIONAL DRIVE | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | HAMBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481390215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102316905 | ||||||||
| FaxNumber: | 8102316906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 04/15/2011 | ||||||||
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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 | 222Z00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotist |
ID Information
| ID | Type | State | Issuer | Description | 510D703120 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 4489299 | 05 | MI | MEDICAID |