Provider Demographics
NPI:1932851003
Name:MILLER, BRIAN (AS)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1372 BENBRANDON CT
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3239
Mailing Address - Country:US
Mailing Address - Phone:419-545-4864
Mailing Address - Fax:
Practice Address - Street 1:1372 BENBRANDON CT
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-3239
Practice Address - Country:US
Practice Address - Phone:419-545-4864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSH946006172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH594519Medicaid
OH03082021282725Medicaid