Healthcare Provider Details

I. General information

NPI: 1154881282
Provider Name (Legal Business Name): JACOB NATHANIEL MILLER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

420 E SUPERIOR ST STE 9-900
CHICAGO IL
60611-4494
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4000
  • Fax:
Mailing address:
  • Phone: 312-503-7975
  • Fax: 312-503-5230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.163453
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number036.163453
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number036.163453
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: