Basic Information
| Provider Information | |||||||||
| NPI: | 1245294966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINNICH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 GEORGE BUSH HWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750823542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143436663 | ||||||||
| FaxNumber: | 2143432814 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 E PRESIDENT GEORGE BUSH HWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750823542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143436663 | ||||||||
| FaxNumber: | 2143432814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | K6891 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | 35-06-5334 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0104210 | 05 | OH | MEDICAID |