MEDICARE: MINEKE E. ETIENNE M.D.

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	207Q00000X	Family Medicine Physician	262777	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811963465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINEKE E. ETIENNE M.D.

Provider Business Mailing Address
First Line	:	600 MCCLELLAN ST
Second Line	:	2 WEST
City	:	SCHENECTADY
State	:	NY
Zip	:	12304-1009
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	624 MCCLELLAN STREET
Second Line	:	SUITE 101
City	:	SCHENECTADY
State	:	NY
Zip	:	12304-1020
Country	:	US
Telephone Number	:	518-382-2260
Fax Number	:	518-347-5007

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	01/19/2015

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