Provider Demographics
NPI:1255442224
Name:MINANOV, ALEXIA ELISABETH (MD)
Entity type:Individual
Prefix:
First Name:ALEXIA
Middle Name:ELISABETH
Last Name:MINANOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30061 SCHOENHERR RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3133
Mailing Address - Country:US
Mailing Address - Phone:586-558-2111
Mailing Address - Fax:586-558-2169
Practice Address - Street 1:30061 SCHOENHERR RD
Practice Address - Street 2:SUITE A
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3133
Practice Address - Country:US
Practice Address - Phone:586-558-2111
Practice Address - Fax:586-558-2169
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM081003208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4688593Medicaid
MI4688593Medicaid