Provider Demographics
NPI:1588663041
Name:MILLER, SALLY (DO)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:DO
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 3318
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-3318
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:616-532-7230
Practice Address - Street 1:906 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-8683
Practice Address - Country:US
Practice Address - Phone:800-968-6866
Practice Address - Fax:616-532-7230
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4602759Medicaid
SM009568OtherBLUE CROSS BLUE SHIELD
MI4602759Medicaid