Provider Demographics
NPI:1568455079
Name:MILLER, GREG J (MD)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:J
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 PINE ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54768-1297
Mailing Address - Country:US
Mailing Address - Phone:715-644-5571
Mailing Address - Fax:
Practice Address - Street 1:1687 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-1571
Practice Address - Country:US
Practice Address - Phone:715-425-6701
Practice Address - Fax:715-425-7075
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42670-20207P00000X
WI42670020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34032100Medicaid
WI34032100Medicaid
WI0030Medicare ID - Type Unspecified