1164424099 NPI number — DR. KENNETH MARC MILLER M.D.

Table of content: DR. KENNETH MARC MILLER M.D. (NPI 1164424099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164424099 NPI number — DR. KENNETH MARC MILLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
KENNETH
Provider Middle Name:
MARC
Provider Name Prefix Text:
DR.
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:
1164424099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 780217
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MASPETH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11378-0217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-639-8827
Provider Business Mailing Address Fax Number:
718-639-8811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 E 79TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10021-0903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-996-6633
Provider Business Practice Location Address Fax Number:
212-996-6677
Provider Enumeration Date:
08/11/2005

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: 207RG0100X , with the licence number:  210303 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1V7471 . This is a "EMPIRE BLUE CROSS BLUE SH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2595177 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2479763 . This is a "OXFORD HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4C0580 . This is a "HEALTH PLAN OF NEW YORK" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02133062 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: MK0303 . This is a "ATLANTIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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