Provider Demographics
NPI:1477901635
Name:MILLER, EDWIN
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:
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 1:160 FAIRVIEW AVE STE 133-299
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-1267
Mailing Address - Country:US
Mailing Address - Phone:518-965-3847
Mailing Address - Fax:
Practice Address - Street 1:160 FAIRVIEW AVE STE 133-299
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-1267
Practice Address - Country:US
Practice Address - Phone:518-965-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-28
Last Update Date:2016-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY81-1915333Medicaid