Healthcare Provider Details

I. General information

NPI: 1003055666
Provider Name (Legal Business Name): JUSTIN MICHAEL MILLER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2009
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LEFFINGWELL AVE NE
GRAND RAPIDS MI
49525-6406
US

IV. Provider business mailing address

1111 LEFFINGWELL AVE NE
GRAND RAPIDS MI
49525-6406
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7101
  • Fax:
Mailing address:
  • Phone: 616-459-7101
  • Fax: 616-954-6483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01677
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601006970
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: