Healthcare Provider Details

I. General information

NPI: 1912192527
Provider Name (Legal Business Name): SANDRENE MILLER M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BALL ST
IRVINGTON NJ
07111-3521
US

IV. Provider business mailing address

202 ELMWYND DR
ORANGE NJ
07050-3111
US

V. Phone/Fax

Practice location:
  • Phone: 973-371-1600
  • Fax:
Mailing address:
  • Phone: 973-672-1722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMA05569500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: