Basic Information
| Provider Information | |||||||||
| NPI: | 1801875877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 S MAIN ST | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372087240 | ||||||||
| FaxNumber: | 9372087242 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 S MAIN ST | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372087240 | ||||||||
| FaxNumber: | 9372087242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 11/01/2018 | ||||||||
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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 | 208G00000X | 35067912 | OH | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 2187128 | 05 | OH | MEDICAID |