Basic Information
| Provider Information | |||||||||
| NPI: | 1437198280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | DANA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERNSTEIN | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | DANA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1510 HUDSON BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302815020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047858660 | ||||||||
| FaxNumber: | 4047858730 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 HUDSON BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302815020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047858660 | ||||||||
| FaxNumber: | 4047858730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 0101234592 | VA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208000000X | 0101234592 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 0101234592 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 2080P0204X | 89760 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 403588700 | 05 | MD | MEDICAID | 1008314420001 | 05 | PA | MEDICAID | 89066FT | 05 | NC | MEDICAID | 006739580 | 05 | VA | MEDICAID |