Provider Demographics
NPI:1881653053
Name:MINNICH, RYAN J (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:MINNICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-4024
Mailing Address - Fax:814-372-2579
Practice Address - Street 1:1100 MILLION DOLLAR HWY
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-2728
Practice Address - Country:US
Practice Address - Phone:814-781-6758
Practice Address - Fax:814-781-3317
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003013A207Q00000X
PAOS014502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102196789Medicaid
IN200800460Medicaid
IN231420016Medicare PIN
PA136019Medicare PIN
H10195Medicare UPIN