Healthcare Provider Details

I. General information

NPI: 1114233012
Provider Name (Legal Business Name): KENNETH MILLER MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W ROGERS AVE
BALTIMORE MD
21215-4131
US

IV. Provider business mailing address

2500 W ROGERS AVE
BALTIMORE MD
21215-4131
US

V. Phone/Fax

Practice location:
  • Phone: 443-240-1682
  • Fax: 855-588-5951
Mailing address:
  • Phone: 443-240-1682
  • Fax: 855-588-5951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TARA L LALLIER
Title or Position: CREDENTIALING/CODING MANAGER
Credential: CHONC
Phone: 321-362-5128