Provider Demographics
NPI:1790755361
Name:MINER, R. EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:R.
Middle Name:EDWARD
Last Name:MINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HAGEN DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2658
Mailing Address - Country:US
Mailing Address - Phone:585-641-0400
Mailing Address - Fax:585-641-0300
Practice Address - Street 1:30 HAGEN DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2658
Practice Address - Country:US
Practice Address - Phone:585-641-0400
Practice Address - Fax:585-641-0300
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPREFERRED CAREOtherPREFERRED CARE
NY00567111Medicaid
NYP010125942OtherBLUE CHOICE
NYPREFERRED CAREOtherPREFERRED CARE
NYMD73994Medicare UPIN