Provider Demographics
NPI:1538123971
Name:MILLER, KENNETH B (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION STREET
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-853-2716
Mailing Address - Fax:508-856-9025
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-853-2716
Practice Address - Fax:508-856-9025
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA428542085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
042472266OtherHEALTHCARE VALUE MANAGEME
784216OtherMVP HEALTH CARE
0143138OtherWELFARE
28037OtherHEALTHY START
9900864OtherFALLON COMMUNITY HEALTH P
C05296OtherBLUE SHIELD HMO BLUE
MA0143138Medicaid
1760952OtherCIGNA HEALTH PLAN
28037OtherCHILDRENS MEDICAL SECURIT
C05296OtherBLUE CARE ELECT
C05296OtherBLUE SHIELD INDEMNITY
042472266OtherTHREE RIVERS
1150178OtherFIRST HEALTH
AA4453OtherHARVARD PILGRIM HEALTHCAR
042472266OtherPRIVATE HEALTHCARE SYSTEM
5910031OtherAETNA US HEALTHCARE
28037OtherHEALTHY START
784216OtherMVP HEALTH CARE
MA0143138Medicaid
C05296Medicare ID - Type UnspecifiedB