Provider Demographics
NPI:1467681387
Name:MINICH, AMANDA LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LYNN
Last Name:MINICH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4939 CROOKS RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1202
Mailing Address - Country:US
Mailing Address - Phone:517-449-2105
Mailing Address - Fax:
Practice Address - Street 1:6450 MAPLE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2259
Practice Address - Country:US
Practice Address - Phone:313-842-7010
Practice Address - Fax:313-842-5150
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018160207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101018160Medicaid
MI5101018160Medicare Oscar/Certification
MI5101018160Medicare NSC
MI5101018160Medicare PIN
MI5101018160Medicaid