Healthcare Provider Details

I. General information

NPI: 1164424099
Provider Name (Legal Business Name): KENNETH MARC MILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E 79TH ST
NEW YORK NY
10021-0903
US

IV. Provider business mailing address

PO BOX 780217
MASPETH NY
11378-0217
US

V. Phone/Fax

Practice location:
  • Phone: 212-996-6633
  • Fax: 212-996-6677
Mailing address:
  • Phone: 718-639-8827
  • Fax: 718-639-8811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number210303
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: