Basic Information
| Provider Information | |||||||||
| NPI: | 1770764177 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDWARD B. MILLER, M.D., INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 LASSEN LN | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960679003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265990 | ||||||||
| FaxNumber: | 5309265740 | ||||||||
| Practice Location | |||||||||
| Address1: | 914 PINE ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309267131 | ||||||||
| FaxNumber: | 5309265740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2007 | ||||||||
| LastUpdateDate: | 01/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5309265990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G27556 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G275560 | 01 | CA | BLUE CROSS | OTHER | 196211500 | 01 | CA | OWCP | OTHER | 006313 | 05 | OR | MEDICAID | 00G275560 | 01 | CA | BLUE SHIELD | OTHER | 00G275560 | 05 | CA | MEDICAID |