Healthcare Provider Details

I. General information

NPI: 1255481727
Provider Name (Legal Business Name): MICHELLE B. MINTZER, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CAISSON HILL RD
FT RILEY KS
66442-7037
US

IV. Provider business mailing address

1228 WESTLOOP PL PMB 214
MANHATTAN KS
66502-2840
US

V. Phone/Fax

Practice location:
  • Phone: 913-111-1111
  • Fax:
Mailing address:
  • Phone: 913-111-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0423698
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0423698
License Number StateKS

VIII. Authorized Official

Name: MICHELLE B. MINTZER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 913-111-1111