Basic Information
| Provider Information | |||||||||
| NPI: | 1538123971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION STREET | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088532716 | ||||||||
| FaxNumber: | 5088569025 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 GOLD STAR BLVD | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088532716 | ||||||||
| FaxNumber: | 5088569025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 02/18/2009 | ||||||||
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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 | 2085N0904X | 42854 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 42854 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 042472266 | 01 | HEALTHCARE VALUE MANAGEME | OTHER | 784216 | 01 | MVP HEALTH CARE | OTHER | 0143138 | 01 | WELFARE | OTHER | 28037 | 01 | HEALTHY START | OTHER | 9900864 | 01 | FALLON COMMUNITY HEALTH P | OTHER | C05296 | 01 | BLUE SHIELD HMO BLUE | OTHER | 0143138 | 05 | MA | MEDICAID | 1760952 | 01 | CIGNA HEALTH PLAN | OTHER | 28037 | 01 | CHILDRENS MEDICAL SECURIT | OTHER | C05296 | 01 | BLUE CARE ELECT | OTHER | C05296 | 01 | BLUE SHIELD INDEMNITY | OTHER | 042472266 | 01 | THREE RIVERS | OTHER | 1150178 | 01 | FIRST HEALTH | OTHER | AA4453 | 01 | HARVARD PILGRIM HEALTHCAR | OTHER | 042472266 | 01 | PRIVATE HEALTHCARE SYSTEM | OTHER | 5910031 | 01 | AETNA US HEALTHCARE | OTHER |