Basic Information
Provider Information | |||||||||
NPI: | 1417953563 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER | ||||||||
FirstName: | HAROLD | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 865 LINCOLN RD | ||||||||
Address2: | STE L10 | ||||||||
City: | BETTENDORF | ||||||||
State: | IA | ||||||||
PostalCode: | 527224159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5633559191 | ||||||||
FaxNumber: | 5633553419 | ||||||||
Practice Location | |||||||||
Address1: | 210 W 53RD ST | ||||||||
Address2: |   | ||||||||
City: | DAVENPORT | ||||||||
State: | IA | ||||||||
PostalCode: | 528062251 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5633863240 | ||||||||
FaxNumber: | 5633863211 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2005 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19332 | IA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 40199 | 01 |   | WELLMARK BC/BS | OTHER | 034791 | 01 |   | HEALTH ALLIANCE | OTHER | 19971 | 01 |   | IOWA HEALTH SOLUTIONS | OTHER | 4143651 | 05 | IA |   | MEDICAID | 4796890009 | 01 |   | DMERC | OTHER | IA0146 | 01 |   | JOHN DEERE HEALTH PLAN | OTHER |