Healthcare Provider Details

I. General information

NPI: 1962414235
Provider Name (Legal Business Name): BRENT JOHN MILLER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S SULLIVAN
FREMONT MI
49412
US

IV. Provider business mailing address

2537 MOMENTUM PL
CHICAGO IL
60689-0001
US

V. Phone/Fax

Practice location:
  • Phone: 231-924-1300
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax: 616-975-1870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704186025
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: