Provider Demographics
NPI:1174036172
Name:MILLER, IDA MAE
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:MAE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18731 COUNTRY CLUB CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-8151
Mailing Address - Country:US
Mailing Address - Phone:734-752-9530
Mailing Address - Fax:
Practice Address - Street 1:18731 COUNTRY CLUB CIR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-8151
Practice Address - Country:US
Practice Address - Phone:734-752-9530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant