Healthcare Provider Details

I. General information

NPI: 1831650845
Provider Name (Legal Business Name): MICHAEL ANDREW MINICHIELLO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2019
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 JOHNSON FERRY RD STE 500
ATLANTA GA
30342-1630
US

IV. Provider business mailing address

960 JOHNSON FERRY RD STE 500
ATLANTA GA
30342-1630
US

V. Phone/Fax

Practice location:
  • Phone: 404-257-0006
  • Fax: 404-851-1316
Mailing address:
  • Phone: 404-257-0006
  • Fax: 404-851-1316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number89184
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: