Provider Demographics
NPI:1770764177
Name:EDWARD B. MILLER, M.D., INC
Entity type:Organization
Organization Name:EDWARD B. MILLER, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-926-5990
Mailing Address - Street 1:635 LASSEN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9003
Mailing Address - Country:US
Mailing Address - Phone:530-926-5990
Mailing Address - Fax:530-926-5740
Practice Address - Street 1:914 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2143
Practice Address - Country:US
Practice Address - Phone:530-926-7131
Practice Address - Fax:530-926-5740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27556207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G275560OtherBLUE CROSS
CA196211500OtherOWCP
OR006313Medicaid
CA00G275560OtherBLUE SHIELD
CA00G275560Medicaid
CA00G275560OtherBLUE SHIELD
CA00G275560OtherBLUE CROSS