Basic Information
| Provider Information | |||||||||
| NPI: | 1922373182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474033239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123552300 | ||||||||
| FaxNumber: | 8123552302 | ||||||||
| Practice Location | |||||||||
| Address1: | 2605 E CREEKS EDGE DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474018368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123552300 | ||||||||
| FaxNumber: | 8123552302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2012 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 01074912A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 01074912A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.