Healthcare Provider Details

I. General information

NPI: 1407903156
Provider Name (Legal Business Name): WESTON PETER MILLER IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE SE EAST BUILDING JOURNEY CLINIC 9E
MINNEAPOLIS MN
55454
US

IV. Provider business mailing address

420 DELAWARE ST SE PEDIATRIC HEMATOLOGY-ONCOLOGY MAYO MAIL CODE 484
MINNEAPOLIS MN
55455-0341
US

V. Phone/Fax

Practice location:
  • Phone: 612-365-8100
  • Fax:
Mailing address:
  • Phone: 612-626-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number104920
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: