Provider Demographics
NPI:1376571265
Name:MILLER, CRAIG B (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:B
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-8741
Practice Address - Street 1:2349 LAKE AVE STE 100
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7836
Practice Address - Country:US
Practice Address - Phone:574-948-5100
Practice Address - Fax:574-948-5499
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050910207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200272700AMedicaid
IN1102406683OtherANTHEM
IN187720043OtherMEDICARE
IN941050080OtherMEDICARE
IN000001397808OtherANTHEM
IN000001397831OtherANTHEM
IN000001266402OtherANTHEM
IN000001397824OtherANTHEM
IN200272700AMedicaid
ININ1933088OtherMEDICARE