Provider Demographics
NPI:1841210895
Name:MILLER, THOMAS PAUL (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PAUL
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 1:3625 CLYDE PARK AVE SW
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49509-4023
Mailing Address - Country:US
Mailing Address - Phone:616-531-6900
Mailing Address - Fax:616-531-5847
Practice Address - Street 1:3625 CLYDE PARK AVE SW
Practice Address - Street 2:SUITE 1
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49509-4023
Practice Address - Country:US
Practice Address - Phone:616-531-6900
Practice Address - Fax:616-531-5847
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051779207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2860745Medicaid
MI0D16314Medicare ID - Type Unspecified
MI2860745Medicaid