Provider Demographics
NPI:1073886438
Name:MINICH, PETER JOHN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:MINICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:PETER
Other - Last Name:MINICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4096
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4096
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037206208800000X
IL036103184208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology