Basic Information
Provider Information | |||||||||
NPI: | 1760582761 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MINNICH | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 29001 | ||||||||
Address2: |   | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 719039001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016221120 | ||||||||
FaxNumber: | 5016221199 | ||||||||
Practice Location | |||||||||
Address1: | 300 WERNER ST | ||||||||
Address2: |   | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 719136406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016221120 | ||||||||
FaxNumber: | 5016221199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 10/31/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N-8350 | AR | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | N-8350 | 01 | AR | MEDICAL LICENSE | OTHER | BM5333240 | 01 | AR | DEA | OTHER | 5J0186972 | 01 | AR | MEDICARE LINKED | OTHER | 123048001 | 05 | AR |   | MEDICAID |