Provider Demographics
NPI:1588632723
Name:MILLER, THOMAS BRYAN III (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BRYAN
Last Name:MILLER
Suffix:III
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 1:266 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-2927
Mailing Address - Country:US
Mailing Address - Phone:978-630-5030
Mailing Address - Fax:978-630-5033
Practice Address - Street 1:266 MAIN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-2927
Practice Address - Country:US
Practice Address - Phone:978-630-5030
Practice Address - Fax:978-630-5033
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9716530Medicaid
MAA30815Medicare ID - Type Unspecified
H08450Medicare UPIN