Healthcare Provider Details

I. General information

NPI: 1861480535
Provider Name (Legal Business Name): KENNETH DAVID MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
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: 860-805-7400
  • Fax: 855-588-5951
Mailing address:
  • Phone: 860-805-7400
  • Fax: 855-588-5951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number238790
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: