Basic Information
| Provider Information | |||||||||
| NPI: | 1346228830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SHADI | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1648 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974401648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416874900 | ||||||||
| FaxNumber: | 5416874904 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 S GARDEN WAY | ||||||||
| Address2: | STE 350 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974018176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417466816 | ||||||||
| FaxNumber: | 5417263177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 06/28/2010 | ||||||||
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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 | 207R00000X | MD25016 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | MD25016 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 022714 | 05 | OR | MEDICAID |