MILLER ORTHOPAEDIC AFFILIATES PC

Provider Demographics

• NPI: 1659379519
• Name: MILLER ORTHOPAEDIC AFFILIATES PC
• Entity Type: Organization
• Organization Name: MILLER ORTHOPAEDIC AFFILIATES PC
• Authorized Official - Title/Position: PRESIDENT
• Authorized Official - Prefix: DR
• Authorized Official - First Name: DANIEL
• Authorized Official - Middle Name: J
• Authorized Official - Last Name: LAROSE
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 712-323-5333
• Mailing Address - Street 1: 1 EDMUNDSON PL
• Mailing Address - Street 2: STE 500
• Mailing Address - City: COUNCIL BLUFFS
• Mailing Address - State: IA
• Mailing Address - Zip Code: 51503-4619
• Mailing Address - Country: US
• Mailing Address - Phone: 712-323-5333
• Mailing Address - Fax: 712-323-3252
• Practice Address - Street 1: 1 EDMUNDSON PLACE
• Practice Address - Street 2: SUITE 500
• Practice Address - City: COUNCIL BLUFFS
• Practice Address - State: IA
• Practice Address - Zip Code: 51503-4619
• Practice Address - Country: US
• Practice Address - Phone: 712-323-5333
• Practice Address - Fax: 712-323-3252
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-07-13
• Last Update Date: 2012-07-16

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207X00000X	Allopathic & Osteopathic Physicians	Orthopaedic Surgery		Group - Multi-Specialty
No	213ES0103X	Podiatric Medicine & Surgery Service Providers	Podiatrist	Foot & Ankle Surgery	Group - Multi-Specialty
No	2251X0800X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist	Orthopedic	Group - Multi-Specialty
No	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
No	332BC3200X	Suppliers	Durable Medical Equipment & Medical Supplies	Customized Equipment
No	335E00000X	Suppliers	Prosthetic/Orthotic Supplier		Group - Multi-Specialty
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Multi-Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IA	0119040	Medicaid
IA	0701830	Medicaid
IA	0701871	Medicaid
IA	0701872	Medicaid
IA	0701873	Medicaid
NE	10025346400	Medicaid
IA	09602	Other	WELLMARK GRP #
IA	0119040	Medicaid
IA	0701872	Medicaid
IA	0393980001	Medicare NSC
NE	10025346400	Medicaid
IA	09602	Medicare PIN
NE	=========13	Medicaid