Provider Demographics
NPI:1942354485
Name:MILLER, KEITH A
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
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 1:416 PIRKLE FERRY RD STE J500
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-9221
Mailing Address - Country:US
Mailing Address - Phone:678-513-8777
Mailing Address - Fax:678-513-8999
Practice Address - Street 1:416 PIRKLE FERRY RD STE J500
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-9221
Practice Address - Country:US
Practice Address - Phone:678-513-8777
Practice Address - Fax:678-513-8999
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA000916213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAN327176Medicaid
GA10059160Medicaid
GA2700108OtherBCBS
GA000901018BMedicaid
GA48SCCKDMedicare ID - Type Unspecified
GAN327176Medicaid
GA10059160Medicaid
GA2700108OtherBCBS