Healthcare Provider Details

I. General information

NPI: 1053400598
Provider Name (Legal Business Name): KEITH R MILLS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 KINGFISHER ROAD
NEW HARBOR ME
04554
US

IV. Provider business mailing address

20 KINGFISHER ROAD
NEW HARBOR ME
04554
US

V. Phone/Fax

Practice location:
  • Phone: 307-262-5949
  • Fax: 844-320-9753
Mailing address:
  • Phone: 307-262-5949
  • Fax: 844-320-9753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberCP206749
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number6639A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: