Provider Demographics
NPI:1891909750
Name:MILLER, MARK ANDREW
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14630 TRANQUIL CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8301
Mailing Address - Country:US
Mailing Address - Phone:574-255-1290
Mailing Address - Fax:574-255-1523
Practice Address - Street 1:236 W EDISON RD
Practice Address - Street 2:SUITE F
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3184
Practice Address - Country:US
Practice Address - Phone:574-255-1290
Practice Address - Fax:574-255-1523
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INPENDING332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1295070001Medicare ID - Type UnspecifiedPROVIDER NUMBER