Provider Demographics
NPI:1588621205
Name:MILLER, TIMOTHY A (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
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 1:5160 HICKORY POINT FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-9778
Mailing Address - Country:US
Mailing Address - Phone:217-330-9788
Mailing Address - Fax:217-330-8945
Practice Address - Street 1:5160 HICKORY POINT FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-9778
Practice Address - Country:US
Practice Address - Phone:217-330-9788
Practice Address - Fax:217-330-8945
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG28399Medicare UPIN
ILK05133Medicare ID - Type Unspecified
ILG28399Medicare UPIN