Provider Demographics
NPI:1780685495
Name:MILLER, MARY CARROLL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:CARROLL
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:124 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4306
Mailing Address - Country:US
Mailing Address - Phone:217-224-0513
Mailing Address - Fax:
Practice Address - Street 1:2628 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3637
Practice Address - Country:US
Practice Address - Phone:217-224-1744
Practice Address - Fax:217-222-5827
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
E87205Medicare UPIN