Healthcare Provider Details

I. General information

NPI: 1811255201
Provider Name (Legal Business Name): JERRY PAUL MILLER III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAY PAUL MILLER

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HOSPITAL DR
COLUMBIA MO
65201-5275
US

IV. Provider business mailing address

4701 CEDAR COALS CT # A
COLUMBIA MO
65203-9072
US

V. Phone/Fax

Practice location:
  • Phone: 573-814-6000
  • Fax:
Mailing address:
  • Phone: 985-515-4779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number304573
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: