Provider Demographics
NPI:1326012295
Name:MILLER, STEPHAN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:J
Last Name:MILLER
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:PO BOX 912882
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2882
Mailing Address - Country:US
Mailing Address - Phone:866-765-0909
Mailing Address - Fax:855-856-8520
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-755-8222
Practice Address - Fax:605-719-4203
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5825207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1326012295Medicaid
CO1326012295Medicaid
ND14159259Medicaid