Provider Demographics
NPI:1992706519
Name:MILLER, MARY KATHLEEN (DO)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHLEEN
Last Name:MILLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 5126
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5126
Mailing Address - Country:US
Mailing Address - Phone:605-369-2627
Mailing Address - Fax:605-369-5627
Practice Address - Street 1:806 8TH STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:SD
Practice Address - Zip Code:57062
Practice Address - Country:US
Practice Address - Phone:605-369-2627
Practice Address - Fax:605-369-5627
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4100208000000X
NE204208000000X
MN45262208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6701142Medicaid
SDG28585Medicare UPIN
SDS100573Medicare PIN