Basic Information
| Provider Information | |||||||||
| NPI: | 1457355828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINCHEY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 938 | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385030938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663135259 | ||||||||
| FaxNumber: | 2053135298 | ||||||||
| Practice Location | |||||||||
| Address1: | 142 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385011760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663135259 | ||||||||
| FaxNumber: | 2053135298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 9053 | TN | X | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 9053 | TN | X | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4007309 | 05 | TN | MEDICAID | BM1132896 | 01 | TN | DEA CERTIFICATE | OTHER |