Basic Information
| Provider Information | |||||||||
| NPI: | 1992706519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | KATHY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5126 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053692627 | ||||||||
| FaxNumber: | 6053695627 | ||||||||
| Practice Location | |||||||||
| Address1: | 806 8TH STREET | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053692627 | ||||||||
| FaxNumber: | 6053695627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2005 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4100 | SD | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 204 | NE | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 45262 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6701142 | 05 | SD | MEDICAID |