1184633059 NPI number — BRADLEY MILLER M.D.

Table of content: BRADLEY MILLER M.D. (NPI 1184633059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184633059 NPI number — BRADLEY MILLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
BRADLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1184633059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 DELAWARE ST SE
Provider Second Line Business Mailing Address:
MMC 404 UNIVERSITY OF MINNESOTA
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-624-5409
Provider Business Mailing Address Fax Number:
612-626-5262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 DELAWARE ST SE
Provider Second Line Business Practice Location Address:
MMC 404 UNIVERSITY OF MINNESOTA
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-624-5409
Provider Business Practice Location Address Fax Number:
612-626-5262
Provider Enumeration Date:
08/07/2006

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: 208000000X , with the licence number:  41017 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0205X , with the licence number: 41017 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33-00127 . This is a "MEDICA CHOICE/SELECT CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP27040 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 126279 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 930078007 . This is a "MN RR" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 006136 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33-00031 . This is a "MEDICA PRIMARY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 548A4MI . This is a "BCBS-MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: PHCS . This is a "929357" identifier . This identifiers is of the category "OTHER".
  • Identifier: 006136 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 96198101860 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".




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