Healthcare Provider Details

I. General information

NPI: 1700982485
Provider Name (Legal Business Name): PAUL DAVID MINNICK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 BEVIER ST
SHELBY MI
49455-1209
US

IV. Provider business mailing address

71 BEVIER ST
SHELBY MI
49455-1209
US

V. Phone/Fax

Practice location:
  • Phone: 231-861-2172
  • Fax: 231-861-5100
Mailing address:
  • Phone: 231-861-2172
  • Fax: 231-861-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101010846
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: