Healthcare Provider Details

I. General information

NPI: 1003245341
Provider Name (Legal Business Name): MATTHEW MINARIK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7750 TOWN CENTRE DR STE 300
BROADVIEW HEIGHTS OH
44147-4040
US

IV. Provider business mailing address

7750 TOWN CENTRE DR STE 300
BROADVIEW HEIGHTS OH
44147-4040
US

V. Phone/Fax

Practice location:
  • Phone: 877-283-8863
  • Fax:
Mailing address:
  • Phone: 877-238-8863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA056138
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601006700
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006700
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004059
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: