Basic Information
| Provider Information | |||||||||
| NPI: | 1700982485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINNICK | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 BEVIER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494551209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318612172 | ||||||||
| FaxNumber: | 2318615100 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 BEVIER ST | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494551209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318612172 | ||||||||
| FaxNumber: | 2318615100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 04/22/2016 | ||||||||
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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 | 207Q00000X | 5101010846 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0851903535 | 01 | MI | BCBS OF MICHIGAN | OTHER | 114135476 | 05 | MI | MEDICAID |