Provider Demographics
NPI:1629012109
Name:MILLER, KENNETH T JR (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:T
Last Name:MILLER
Suffix:JR
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 1:969 OAK RIDGE TURNPIKE, PMB 222
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-8832
Mailing Address - Country:US
Mailing Address - Phone:865-482-4028
Mailing Address - Fax:865-481-3257
Practice Address - Street 1:160A W TENNESSE AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6940
Practice Address - Country:US
Practice Address - Phone:865-835-3740
Practice Address - Fax:865-385-3742
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
TNMD0000010495174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3163832Medicaid
TN070200Medicare UPIN
TN3163835Medicare PIN
TN3063833Medicare PIN