1760586283 NPI number — SUSAN MILLER PT

Table of content: SUSAN MILLER PT (NPI 1760586283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760586283 NPI number — SUSAN MILLER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

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:
1760586283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 711185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84171-1185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-942-3311
Provider Business Mailing Address Fax Number:
801-942-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3225 W GORDON AVE
Provider Second Line Business Practice Location Address:
3
Provider Business Practice Location Address City Name:
LAYTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84041-6508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-497-0800
Provider Business Practice Location Address Fax Number:
801-497-0807
Provider Enumeration Date:
09/13/2006

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: 225100000X , with the licence number:  53276982401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1760586283 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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