1104832294 NPI number — MR. DANIEL JASON MILLER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104832294 NPI number — MR. DANIEL JASON MILLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
DANIEL
Provider Middle Name:
JASON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
DANIEL
Provider Other Middle Name:
JASON
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1104832294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
258 GEREMMA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-3334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-283-8421
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3136 NAMEOKI RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANITE CITY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62040-5013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-452-2300
Provider Business Practice Location Address Fax Number:
618-452-0373
Provider Enumeration Date:
07/31/2006

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: 111N00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06026803 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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