Basic Information
| Provider Information | |||||||||
| NPI: | 1700848264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 LASSEN LN | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960679003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 914 PINE ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 10/21/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD10363 | OR | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | G27556 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G275560 | 01 | CA | BLUE SHIELD | OTHER | 00G275560 | 05 | CA | MEDICAID | 00G275560 | 01 | CA | BLUE CROSS | OTHER | 006313 | 05 | OR | MEDICAID |