MEDICARE: KENNETH R MINK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207NS0135X	Procedural Dermatology Physician	MD054676L	PA

General Provider Information

NPI Number	:	1932102829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH R MINK MD

Provider Business Mailing Address
First Line	:	3800 W 12TH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-3380
Country	:	US
Telephone Number	:	814-833-0399
Fax Number	:	814-833-4999

Provider Business Practice Location Address
First Line	:	3800 W 12TH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-3380
Country	:	US
Telephone Number	:	814-833-0399
Fax Number	:	814-833-4999

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	11/28/2007

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