Provider Demographics
NPI:1841280831
Name:MILLER, RONALD (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 RICHMOND AVE E
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4652
Mailing Address - Country:US
Mailing Address - Phone:217-234-3937
Mailing Address - Fax:217-234-3930
Practice Address - Street 1:220 RICHMOND AVE E
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4652
Practice Address - Country:US
Practice Address - Phone:217-234-3937
Practice Address - Fax:217-234-3930
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060611174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD16616Medicare UPIN
IL782420Medicare ID - Type Unspecified