Provider Demographics
NPI:1346454808
Name:MINICH, JOSEPH THOMAS (OTHER)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:THOMAS
Last Name:MINICH
Suffix:
Gender:M
Credentials:OTHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9517 69TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8114
Mailing Address - Country:US
Mailing Address - Phone:708-280-7356
Mailing Address - Fax:
Practice Address - Street 1:2410 SAMPSON ST BLDG 237
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-2942
Practice Address - Country:US
Practice Address - Phone:847-688-2469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman