Healthcare Provider Details

I. General information

NPI: 1104756667
Provider Name (Legal Business Name): MILLER DIVERSIFIED CLINICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7203 SARAH ST APT 1
MAPLEWOOD MO
63143-2418
US

IV. Provider business mailing address

PO BOX 434091
MAPLEWOOD MO
63143-4094
US

V. Phone/Fax

Practice location:
  • Phone: 314-669-1445
  • Fax:
Mailing address:
  • Phone: 314-669-1445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BERNARD VICTOR MILLER III
Title or Position: CEO/MEMBER
Credential: MD
Phone: 314-669-1445