Healthcare Provider Details

I. General information

NPI: 1104055854
Provider Name (Legal Business Name): RICHARD ERIC MINNIHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: R ERIC MINNIHAN M.D.

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 CRANBERRY BLVD
WESTON WI
54476-5216
US

IV. Provider business mailing address

3301 CRANBERRY BLVD
WESTON WI
54476-5216
US

V. Phone/Fax

Practice location:
  • Phone: 715-393-3900
  • Fax:
Mailing address:
  • Phone: 715-393-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301094698
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number57415
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number57415
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: