Basic Information
| Provider Information | |||||||||
| NPI: | 1326019100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374351445 | ||||||||
| FaxNumber: | 9374397552 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374351445 | ||||||||
| FaxNumber: | 9374397552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 07/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35-055796 | OH | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VF0040X | 35.055796 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0686931 | 05 | OH | MEDICAID |