Provider Demographics
NPI:1376708651
Name:MILLER FAMILY MEDICINE, SC
Entity Type:Organization
Organization Name:MILLER FAMILY MEDICINE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN KEVIN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:309-840-2177
Mailing Address - Street 1:1503 VALLE VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6239
Mailing Address - Country:US
Mailing Address - Phone:309-840-2177
Mailing Address - Fax:
Practice Address - Street 1:1503 VALLE VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6239
Practice Address - Country:US
Practice Address - Phone:309-840-2177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105875207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty