Provider Demographics
NPI:1114233012
Name:KENNETH MILLER MD LLC
Entity Type:Organization
Organization Name:KENNETH MILLER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/CODING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LALLIER
Authorized Official - Suffix:
Authorized Official - Credentials:CHONC
Authorized Official - Phone:321-362-5128
Mailing Address - Street 1:2500 W ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4131
Mailing Address - Country:US
Mailing Address - Phone:443-240-1682
Mailing Address - Fax:855-588-5951
Practice Address - Street 1:2500 W ROGERS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4131
Practice Address - Country:US
Practice Address - Phone:443-240-1682
Practice Address - Fax:855-588-5951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD220065100Medicaid
MD445791900Medicaid