Basic Information
| Provider Information | |||||||||
| NPI: | 1891053922 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEPHEN A. MILLER,D.O.,P.A. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 WEST 8TH | ||||||||
| Address2: | |||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673373101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202510777 | ||||||||
| FaxNumber: | 6202514173 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | COFFEYVILLE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 673373101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202510777 | ||||||||
| FaxNumber: | 6202514173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 04/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6202510777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | 0521872 | KS | Y | Managed Care Organizations | Exclusive Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 100206010B | 05 | KS | MEDICAID |