MEDICARE: MICHELLE B. MINTZER, M.D., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	0423698	KS
2	2084P0800X	Psychiatry Physician	0423698	KS

General Provider Information

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

Provider Business Mailing Address
First Line	:	1228 WESTLOOP PL
Second Line	:	PMB 214
City	:	MANHATTAN
State	:	KS
Zip	:	66502-2840
Country	:	US
Telephone Number	:	913-111-1111
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 CAISSON HILL RD
Second Line	:
City	:	FT RILEY
State	:	KS
Zip	:	66442-7037
Country	:	US
Telephone Number	:	913-111-1111
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHELLE B. MINTZER
Credential	:	M.D.
Telephone Number	:	913-111-1111

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	08/23/2013

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