Basic Information
| Provider Information | |||||||||
| NPI: | 1457321333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 435 | ||||||||
| Address2: | |||||||||
| City: | SISTERS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977590435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415499606 | ||||||||
| FaxNumber: | 5412788379 | ||||||||
| Practice Location | |||||||||
| Address1: | 354 ADAMS | ||||||||
| Address2: | |||||||||
| City: | SISTERS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415499606 | ||||||||
| FaxNumber: | 5415490593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 08/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D021606 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 134147 | 05 | OR | MEDICAID |