Basic Information
| Provider Information | |||||||||
| NPI: | 1013455922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | RUSSELL | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50505 SCHOENHERR RD | ||||||||
| Address2: | STE. 340 | ||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483153140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867318400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50505 SCHOENHERR RD | ||||||||
| Address2: | STE. 340 | ||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483153140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867318400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2017 | ||||||||
| LastUpdateDate: | 02/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 4704281165 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.