Basic Information
| Provider Information | |||||||||
| NPI: | 1326334384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | COURTNEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MITCHELL | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | COURTNEY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 407 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304750407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125388484 | ||||||||
| FaxNumber: | 9125388665 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304744770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125388484 | ||||||||
| FaxNumber: | 9125388665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4799 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.