Provider Demographics
NPI:1255394714
Name:MILLER, MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 PIERCE ST
Mailing Address - Street 2:STE 205
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5512
Mailing Address - Country:US
Mailing Address - Phone:570-287-1400
Mailing Address - Fax:
Practice Address - Street 1:676 WYOMING AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3857
Practice Address - Country:US
Practice Address - Phone:570-287-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008632L207V00000X
PA05008632L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001729923Medicaid
PA001729923Medicaid
PA022582Medicare ID - Type Unspecified