Provider Demographics
NPI:1902843600
Name:MILLER, THOMAS WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WILLIAM
Last Name:MILLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11417 HANSON BLVD NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3719
Mailing Address - Country:US
Mailing Address - Phone:763-754-1482
Mailing Address - Fax:763-754-6116
Practice Address - Street 1:11417 HANSON BLVD NW
Practice Address - Street 2:SUITE 101
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3719
Practice Address - Country:US
Practice Address - Phone:763-754-1482
Practice Address - Fax:763-754-6116
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1759111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN223027500Medicaid
MN350000024Medicare ID - Type Unspecified
MN223027500Medicaid