1558441238 NPI number — DR. KENNETH D MILLER MD

Table of content: DR. KENNETH D MILLER MD (NPI 1558441238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558441238 NPI number — DR. KENNETH D MILLER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
KENNETH
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1558441238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 95000 LB#7550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19195-7550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-362-1735
Provider Business Mailing Address Fax Number:
973-290-7495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 OLD BROOKSIDE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANDOLPH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-895-4000
Provider Business Practice Location Address Fax Number:
973-895-3310
Provider Enumeration Date:
10/16/2006

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: 207R00000X , with the licence number:  MA34422 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: IP099 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0736771010 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0920401 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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