Provider Demographics
NPI:1831823087
Name:MILLER, EDWARD MICHAEL
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:MICHAEL
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EDDIE
Other - Middle Name:MICHAEL
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1411 15TH ST S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5652
Mailing Address - Country:US
Mailing Address - Phone:608-797-3246
Mailing Address - Fax:
Practice Address - Street 1:1820 PINE ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3750
Practice Address - Country:US
Practice Address - Phone:608-797-3246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program