Provider Demographics
NPI:1356338537
Name:MINNIHAN, KEVIN T (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:T
Last Name:MINNIHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-0005
Mailing Address - Country:US
Mailing Address - Phone:314-895-3828
Mailing Address - Fax:314-895-3827
Practice Address - Street 1:10 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ST PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1659
Practice Address - Country:US
Practice Address - Phone:314-895-3828
Practice Address - Fax:314-895-3827
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR5P29207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203716923Medicaid
MO050059529OtherRAILROAD MEDICARE
MOF12763Medicare UPIN
MO203716923Medicaid