Provider Demographics
NPI:1669599551
Name:MILLER, KENNETH B JR (PT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:B
Last Name:MILLER
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 AMESBURY CT
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-1222
Mailing Address - Country:US
Mailing Address - Phone:410-544-7983
Mailing Address - Fax:
Practice Address - Street 1:9110 PHILADELPHIA RD
Practice Address - Street 2:SUITE 208
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4301
Practice Address - Country:US
Practice Address - Phone:443-460-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS484-0003OtherCAREFIRST
MD323-541OtherMAMSI
MDS484-0003OtherCAREFIRST