Healthcare Provider Details

I. General information

NPI: 1073990529
Provider Name (Legal Business Name): KYLE LAMAR MILLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 01/04/2022
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20201 CRAWFORD AVE ATTN: POSTDOCTORAL EDUCATION
OLYMPIA FIELDS IL
60461-1010
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number05-44838
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2021025229
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number02005427A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: