Provider Demographics
NPI:1467648808
Name:MILLER, DEREK RUSSELL
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:RUSSELL
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 1:5109 HORSESHOE COVE RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-7530
Mailing Address - Country:US
Mailing Address - Phone:706-202-2492
Mailing Address - Fax:
Practice Address - Street 1:5109 HORSESHOE COVE RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-7530
Practice Address - Country:US
Practice Address - Phone:706-202-2492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0039902279C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredCritical Care