Healthcare Provider Details

I. General information

NPI: 1659379519
Provider Name (Legal Business Name): MILLER ORTHOPAEDIC AFFILIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EDMUNDSON PLACE SUITE 500
COUNCIL BLUFFS IA
51503-4619
US

IV. Provider business mailing address

1 EDMUNDSON PL STE 500
COUNCIL BLUFFS IA
51503-4619
US

V. Phone/Fax

Practice location:
  • Phone: 712-323-5333
  • Fax: 712-323-3252
Mailing address:
  • Phone: 712-323-5333
  • Fax: 712-323-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL J. LAROSE
Title or Position: PRESIDENT
Credential: MD
Phone: 712-323-5333