Provider Demographics
NPI:1912903899
Name:MILLER, ROGER L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:L
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:PO BOX 15730
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61132-5730
Mailing Address - Country:US
Mailing Address - Phone:815-964-3333
Mailing Address - Fax:815-864-3331
Practice Address - Street 1:2300 N ROCKTON AVE
Practice Address - Street 2:STE 304
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3619
Practice Address - Country:US
Practice Address - Phone:815-964-3333
Practice Address - Fax:815-864-3331
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL194361OtherPERSONAL CARE
IL036062833 2Medicaid
ILD14760Medicare UPIN
IL036062833 2Medicaid