Provider Demographics
NPI:1245416619
Name:ADAM S. MINER, MD, PA
Entity Type:Organization
Organization Name:ADAM S. MINER, MD, PA
Other - Org Name:PROMENADE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:MINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-234-6868
Mailing Address - Street 1:PO BOX 796534
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75379-6534
Mailing Address - Country:US
Mailing Address - Phone:972-234-6868
Mailing Address - Fax:972-238-1235
Practice Address - Street 1:1120 W CAMPBELL RD
Practice Address - Street 2:SUITE 111
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2976
Practice Address - Country:US
Practice Address - Phone:972-234-6868
Practice Address - Fax:972-238-1235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2689207Q00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080185401Medicaid
TX080185401Medicaid