Healthcare Provider Details

I. General information

NPI: 1215230651
Provider Name (Legal Business Name): JESS RANSOM MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W MARQUAM ST
MOUNT ANGEL OR
97362
US

IV. Provider business mailing address

1497 W ELK AVE SUITE 21
ELIZABETHTON TN
37643-2895
US

V. Phone/Fax

Practice location:
  • Phone: 503-845-2000
  • Fax: 503-845-2384
Mailing address:
  • Phone: 423-542-7420
  • Fax: 423-542-7425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101247988
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number53724
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number186079
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: