Provider Demographics
NPI:1881648681
Name:MILLER, GORDON CHASON (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:CHASON
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 1:1506 E EVANS ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4364
Mailing Address - Country:US
Mailing Address - Phone:229-243-0740
Mailing Address - Fax:229-243-7384
Practice Address - Street 1:1506 E EVANS ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4364
Practice Address - Country:US
Practice Address - Phone:229-243-0740
Practice Address - Fax:229-243-7384
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9888207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000012757AMedicaid
GA235747OtherBLUE CROSS BLUE SHIELD
GA055001894AMedicaid
GA063603652OtherRAILROAD MEDICARE
GA000012757AMedicaid
06BDCHKMedicare PIN