1104890623 NPI number — DR. KAY T. MILLER M.D.

Table of content: DR. KAY T. MILLER M.D. (NPI 1104890623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104890623 NPI number — DR. KAY T. MILLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
KAY
Provider Middle Name:
T.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAYLOR
Provider Other First Name:
KAY
Provider Other Middle Name:
SUZANNE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104890623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
MANAGED CARE DEPT
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6770 DIXIE HWY
Provider Second Line Business Practice Location Address:
SUITE #106
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48346-2087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-625-0300
Provider Business Practice Location Address Fax Number:
248-625-0363
Provider Enumeration Date:
02/13/2006

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: 2085R0001X , with the licence number:  4301058072 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102307 . This is a "GREAT LAKES HEALTH PLAN - AOAM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4192919 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115615 . This is a "CARE CHOICES HMO PROV. #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4253925 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102299 . This is a "GREAT LAKES HEALTH PLAN - XRAY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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