Provider Demographics
NPI:1720094477
Name:MILLER, THOMAS G (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:MILLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4808
Mailing Address - Country:US
Mailing Address - Phone:207-773-7406
Mailing Address - Fax:
Practice Address - Street 1:86 DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4808
Practice Address - Country:US
Practice Address - Phone:207-773-7406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1042103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME035275OtherANTHEM BC/BS PROVIDER ID
ME231050000Medicaid
MEMM896601Medicare PIN
ME231050000Medicaid