Basic Information
| Provider Information | |||||||||
| NPI: | 1225498496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | PAGE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012273255 | ||||||||
| FaxNumber: | 9012273205 | ||||||||
| Practice Location | |||||||||
| Address1: | 703 CLINTON PKWY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390565245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017084205 | ||||||||
| FaxNumber: | 6017084707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT5907 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.