Healthcare Provider Details

I. General information

NPI: 1467648808
Provider Name (Legal Business Name): MR. DEREK RUSSELL MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5109 HORSESHOE COVE RD
BLAIRSVILLE GA
30512-7530
US

IV. Provider business mailing address

5109 HORSESHOE COVE RD
BLAIRSVILLE GA
30512-7530
US

V. Phone/Fax

Practice location:
  • Phone: 706-202-2492
  • Fax:
Mailing address:
  • Phone: 706-202-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number003990
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: