Provider Demographics
NPI:1568560860
Name:BICANICH, BARRY WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:WILLIAM
Last Name:BICANICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 TIMMY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1313
Mailing Address - Country:US
Mailing Address - Phone:651-452-2999
Mailing Address - Fax:
Practice Address - Street 1:3404 UNIVERSITY AVE SE # 3406
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3328
Practice Address - Country:US
Practice Address - Phone:612-331-4529
Practice Address - Fax:612-331-4148
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN29320BIOtherBLUE CROSS PIN
MN01448BIOtherBLUE CROSS PROVIDER #
MNTT40068Medicare UPIN