Provider Demographics
NPI:1699380188
Name:MILLER, RUSSELL PAUL (CEO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:PAUL
Last Name:MILLER
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 ELM ST
Mailing Address - Street 2:
Mailing Address - City:STRUTHERS
Mailing Address - State:OH
Mailing Address - Zip Code:44471-1905
Mailing Address - Country:US
Mailing Address - Phone:330-676-2551
Mailing Address - Fax:
Practice Address - Street 1:87 ELM ST
Practice Address - Street 2:
Practice Address - City:STRUTHERS
Practice Address - State:OH
Practice Address - Zip Code:44471-1905
Practice Address - Country:US
Practice Address - Phone:330-676-2551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6705696253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6705696Medicaid