Basic Information
| Provider Information | |||||||||
| NPI: | 1215230651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JESS | ||||||||
| MiddleName: | RANSOM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1497 W ELK AVE | ||||||||
| Address2: | SUITE 21 | ||||||||
| City: | ELIZABETHTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376432895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235427420 | ||||||||
| FaxNumber: | 4235427425 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 W MARQUAM ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT ANGEL | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038452000 | ||||||||
| FaxNumber: | 5038452384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2010 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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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 | 207Q00000X | 0101247988 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 53724 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 186079 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1215230651 | 05 | VA | MEDICAID | Q021281 | 05 | TN | MEDICAID |