Provider Demographics
NPI:1336250547
Name:RUSSELL WM MILLER MD PC
Entity Type:Organization
Organization Name:RUSSELL WM MILLER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-879-8441
Mailing Address - Street 1:44199 DEQUINDRE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-1128
Mailing Address - Country:US
Mailing Address - Phone:248-879-8441
Mailing Address - Fax:248-879-6841
Practice Address - Street 1:44199 DEQUINDRE
Practice Address - Street 2:SUITE 250
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1128
Practice Address - Country:US
Practice Address - Phone:248-879-8441
Practice Address - Fax:248-879-6841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRM035118207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI148722310Medicaid
0P00270Medicare Oscar/Certification
A74190Medicare UPIN