Provider Demographics
NPI:1275523045
Name:MILES, ANDREA R (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:MILES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 REGENCY PARK DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7080
Mailing Address - Country:US
Mailing Address - Phone:770-957-4195
Mailing Address - Fax:770-898-6337
Practice Address - Street 1:101 REGENCY PARK DR
Practice Address - Street 2:SUITE 150
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-7080
Practice Address - Country:US
Practice Address - Phone:770-957-4195
Practice Address - Fax:770-898-6337
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA54318207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA37BBGTZMedicare ID - Type Unspecified
P00219736Medicare PIN
GAI26359Medicare UPIN
GA313962OtherWELLCARE
GAGRP1806Medicare PIN
GA10033105OtherAMERIGROUP
GA1153580002OtherPEACHSTATE
GA193543158AMedicaid
511I110322Medicare PIN