1972500346 NPI number — TIMOTHY E MILLER CPO

Table of content: TIMOTHY E MILLER CPO (NPI 1972500346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972500346 NPI number — TIMOTHY E MILLER CPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
TIMOTHY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972500346
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1764 YANKEE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LIBERTY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52765-9303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-785-6145
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4505 UTICA RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BETTENDORF
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52722-1641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-344-4206
Provider Business Practice Location Address Fax Number:
563-344-4209
Provider Enumeration Date:
06/30/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 421429042001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0118281 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".