Provider Demographics
NPI:1396358537
Name:MILLER, MAXWELL S
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:S
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 FERNWOOD DR # 2
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6241
Mailing Address - Country:US
Mailing Address - Phone:502-498-9730
Mailing Address - Fax:
Practice Address - Street 1:1021 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-5252
Practice Address - Country:US
Practice Address - Phone:502-498-9730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer