Basic Information
| Provider Information | |||||||||
| NPI: | 1225114663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | DEVEREUX | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 RIVERSIDE DR STE 1600 | ||||||||
| Address2: | |||||||||
| City: | BOURBONNAIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609145406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158027090 | ||||||||
| FaxNumber: | 8158027091 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 RIVERSIDE DR STE 1600 | ||||||||
| Address2: | |||||||||
| City: | BOURBONNAIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609145406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158027090 | ||||||||
| FaxNumber: | 8158027091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301066073 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 036147403 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036147403 | 05 | IL | MEDICAID |