Basic Information
Provider Information | |||||||||
NPI: | 1386622157 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MINKINA | ||||||||
FirstName: | NATALY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 291 INDEPENDENCE DR | ||||||||
Address2: | INTERNAL MEDICINE | ||||||||
City: | CHESTNUT HILL | ||||||||
State: | MA | ||||||||
PostalCode: | 024673628 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6175416505 | ||||||||
FaxNumber: | 6175416444 | ||||||||
Practice Location | |||||||||
Address1: | 850 BOYLSTON ST | ||||||||
Address2: |   | ||||||||
City: | CHESTNUT HILL | ||||||||
State: | MA | ||||||||
PostalCode: | 024672477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177329900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2006 | ||||||||
LastUpdateDate: | 02/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 160133 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0121291 | 05 | MA |   | MEDICAID | 0410481 | 01 | MD | UNITED | OTHER | 3690018 | 01 | MA | AETNA | OTHER | 7975828-008 | 01 | MA | CIGNA | OTHER | 160133 | 01 | MA | TUFTS | OTHER | 69891 | 01 | MA | HPHC | OTHER | J22762 | 01 | MA | BCBS | OTHER |