Provider Demographics
NPI:1831120682
Name:MINICH, DIANE M (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:MINICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:86 CONSERVATORY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-4289
Mailing Address - Country:US
Mailing Address - Phone:330-753-8802
Mailing Address - Fax:330-753-8841
Practice Address - Street 1:86 CONSERVATORY DR
Practice Address - Street 2:SUITE B
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203-4289
Practice Address - Country:US
Practice Address - Phone:330-753-8802
Practice Address - Fax:330-753-8841
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35052203M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2003549Medicaid
9330191OtherMEDICARE BILLING NUMBER
OH000000256797OtherANTHEM
OH481283219027OtherCARESOURCE
OH0598034Medicare PIN
OHA16874Medicare UPIN