Provider Demographics
NPI:1013979145
Name:MINNICH, KEITH ALAN (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:MINNICH
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 1:250 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3363
Mailing Address - Country:US
Mailing Address - Phone:610-988-8589
Mailing Address - Fax:610-988-5976
Practice Address - Street 1:6TH AVE & SPRUCE ST
Practice Address - Street 2:
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611
Practice Address - Country:US
Practice Address - Phone:610-988-8589
Practice Address - Fax:610-988-5976
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042670E207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012407270001Medicaid
E81429Medicare UPIN
PA0012407270001Medicaid