Basic Information
| Provider Information | |||||||||
| NPI: | 1669459145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | BLDG B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
| FaxNumber: | 2604585636 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 N SAWYER ROAD | ||||||||
| Address2: | WOMEN'S HEALTHCARE OF NE INDIANA | ||||||||
| City: | KENDALLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603478030 | ||||||||
| FaxNumber: | 2603478035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
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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 | 207V00000X | 01041491A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000000374260 | 01 | IN | ANTHEM | OTHER | P00288189 | 01 | IN | RAILROAD MEDICARE | OTHER | 02341 | 01 | AETNA | OTHER | 18571 | 01 | IN | PHYSICIANS HEALTH PLAN | OTHER | 100077390 | 05 | IN | MEDICAID |