Provider Demographics
NPI:1790777241
Name:MILLER, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MILLER
Suffix:
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 1:10095 INVESTMENT WAY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-4798
Mailing Address - Country:US
Mailing Address - Phone:859-301-9070
Mailing Address - Fax:859-301-9075
Practice Address - Street 1:10095 INVESTMENT WAY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4798
Practice Address - Country:US
Practice Address - Phone:859-301-9070
Practice Address - Fax:859-301-9075
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24910207Q00000X, 207QS0010X
OH35051327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0721133Medicaid
KY64249105Medicaid
OH0721133Medicaid
KYP00138581Medicare PIN
KY64249105Medicaid
KY0969490Medicare PIN