Provider Demographics
NPI:1528392347
Name:MILES, CASEY LAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:LAINE
Last Name:MILES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-559-9378
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:615 7TH AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-6921
Practice Address - Country:US
Practice Address - Phone:270-846-4800
Practice Address - Fax:270-846-4800
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2024-02-01
Deactivation Date:2018-08-29
Deactivation Code:
Reactivation Date:2018-09-06
Provider Licenses
StateLicense IDTaxonomies
KY49327208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100416040Medicaid