Healthcare Provider Details

I. General information

NPI: 1679534762
Provider Name (Legal Business Name): JERRY ALLAN MILLER JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1807
US

IV. Provider business mailing address

1245 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1807
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-0389
  • Fax: 706-651-0729
Mailing address:
  • Phone: 706-868-0389
  • Fax: 706-651-0729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number018708
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number018708
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: