Provider Demographics
NPI:1013924547
Name:MILLER, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
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 1:201 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16550-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-6139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428240207P00000X
NY265386-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1330913OtherAETNA
P00370676OtherRR MEDICARE
NY02798929OtherNY MEDICAL ASSISTANCE
PA1873059OtherBLUE SHIELD
OH2613612OtherOH MEDICAL ASSISTANCE
PA1016693090001Medicaid
WV1069929OtherWEST VIRGINIA WORK COMP
PA718516OtherUPMC
NY00027641601OtherUNIVERA
PA1554274OtherGATEWAY
PA194151OtherUNISON
PA194151OtherUNISON
NY00027641601OtherUNIVERA