Provider Demographics
NPI:1164403689
Name:ANDERSON, MILES C (MD)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:
Practice Address - Street 1:21 HOSPITAL DR STE 125
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2455
Practice Address - Country:US
Practice Address - Phone:386-586-7005
Practice Address - Fax:844-867-3940
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259553200Medicaid
FL35931OtherBLUE CROSS/BLUE SHIELD
P00046074OtherRAILROAD MEDICARE
FL35931OtherBLUE CROSS/BLUE SHIELD
H30068Medicare UPIN