MEDICARE: DR. THEODORE H MILLER M.D., PHD.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YX0905X	Otolaryngology/Facial Plastic Surgery Physician	25084	KY
2	207Y00000X	Otolaryngology Physician	25084	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000033216	OTHER		ANTHEM BC/BS

General Provider Information

NPI Number	:	1720078264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE H MILLER M.D., PHD.

Provider Business Mailing Address
First Line	:	40 N GRAND AVE STE 103
Second Line	:
City	:	FORT THOMAS
State	:	KY
Zip	:	41075-1765
Country	:	US
Telephone Number	:	859-781-4900
Fax Number	:	859-572-3039

Provider Business Practice Location Address
First Line	:	40 NORTH GRAND AVE.
Second Line	:	SUITE 101
City	:	FT. THOMAS
State	:	KY
Zip	:	41075
Country	:	US
Telephone Number	:	859-781-4900
Fax Number	:	859-781-3039

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	04/27/2018

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