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General NPI Number Information
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NPI Number | 1316474976
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Entity Type | Individual
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Provider Name | MICHAEL THOMAS GINNETTI MD
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Gender | Male
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Dates
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Enumeration Date | 05/15/2017
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Last Update Date | 11/23/2022
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Provider Practice Location Address
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Address Line | 1015 S MERCER AVE STE GF7
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City | BLOOMINGTON
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State | IL
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Zip | 61701-7107
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Country | US
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Telephone | 309-660-8442
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Fax |
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Provider Business Mailing Address
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Address Line | 1015 S MERCER AVE STE GF7
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City | BLOOMINGTON
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State | IL
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Zip | 61701-7107
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Country | US
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Telephone | 309-660-8442
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Fax | 309-846-6155
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | R-11187
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | R-11187
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License Number State | IA
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Taxonomy #4
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 036.156711
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License Number State | IL
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