Basic Information
| Provider Information | |||||||||
| NPI: | 1720019599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13331 PARK WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490978494 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6016 LOVERS LN | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490023050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693290934 | ||||||||
| FaxNumber: | 2693290965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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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 | 225100000X | 5501009456 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1720019599 | 01 | MI | NPI | OTHER | 650C913290 | 01 | MI | BCBSM | OTHER | 1649216144 | 01 | MI | GROUP NPI | OTHER | 5501009459 | 01 | MI | STATE OF MICHIGAN | OTHER |