Provider Demographics
NPI:1750382396
Name:MILLER, RODNEY LEE (MD)
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:LEE
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1239 E MAIN ST
Mailing Address - Street 2:P O BOX 3988
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3114
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-351-4821
Practice Address - Street 1:220 S PARK AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3612
Practice Address - Country:US
Practice Address - Phone:618-942-2002
Practice Address - Fax:618-942-4477
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036106959208600000X
IL036-106959207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106959Medicaid
IL3932056OtherBCBS
IL721089OtherAETNA
KY7100114770Medicaid
IL1750382396OtherBCBS OF IL
KY7100114770Medicaid
ILIL1943004Medicare PIN
IL1750382396OtherBCBS OF IL