Basic Information
Provider Information | |||||||||
NPI: | 1023257599 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | JEREMIAH | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 337 | ||||||||
Address2: |   | ||||||||
City: | SCARBRO | ||||||||
State: | WV | ||||||||
PostalCode: | 259170337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044692905 | ||||||||
FaxNumber: | 3044651518 | ||||||||
Practice Location | |||||||||
Address1: | 302 W. MAIN ST. | ||||||||
Address2: |   | ||||||||
City: | SOPHIA | ||||||||
State: | WV | ||||||||
PostalCode: | 25921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044692905 | ||||||||
FaxNumber: | 3046834307 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2009 | ||||||||
LastUpdateDate: | 03/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3105 | WV | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1023257599 | 05 | WV |   | MEDICAID |