MEDICARE: MILLER ORTHOPAEDIC AFFILIATES PC

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	213ES0103X	Foot & Ankle Surgery Podiatrist
2	2251X0800X	Orthopedic Physical Therapist
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	332BC3200X	Customized Equipment (DME)
5	335E00000X	Prosthetic/Orthotic Supplier
6	363A00000X	Physician Assistant
7	363L00000X	Nurse Practitioner
8	207X00000X	Orthopaedic Surgery Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	09602	OTHER	IA	WELLMARK GRP #

NPI Number	:	1659379519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLER ORTHOPAEDIC AFFILIATES PC

Provider Business Mailing Address
First Line	:	1 EDMUNDSON PL
Second Line	:	STE 500
City	:	COUNCIL BLUFFS
State	:	IA
Zip	:	51503-4619
Country	:	US
Telephone Number	:	712-323-5333
Fax Number	:	712-323-3252

Provider Business Practice Location Address
First Line	:	1 EDMUNDSON PLACE
Second Line	:	SUITE 500
City	:	COUNCIL BLUFFS
State	:	IA
Zip	:	51503-4619
Country	:	US
Telephone Number	:	712-323-5333
Fax Number	:	712-323-3252

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DANIEL J. LAROSE
Credential	:	MD
Telephone Number	:	712-323-5333

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	07/16/2012