Basic Information
| Provider Information | |||||||||
| NPI: | 1366428229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINNIS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 860 BETHESDA DR | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404544651 | ||||||||
| FaxNumber: | 7404544653 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 FOREST AVE | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437012868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404548502 | ||||||||
| FaxNumber: | 7404548641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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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 | 208000000X | 35054785M | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000177369 | 01 | OH | UNISON PIN | OTHER | 0701244 | 05 | OH | MEDICAID | 000000019439 | 01 | OH | ANTHEM PIN | OTHER | 0989499 | 01 | OH | GROUP MEDICAID | OTHER | 1204559 | 01 | OH | UHC PIN | OTHER | 311413469027 | 01 | OH | CARESOURCE PIN | OTHER |