Healthcare Provider Details

I. General information

NPI: 1366768087
Provider Name (Legal Business Name): MICHAEL MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 03/25/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PEACH ST STE 102 SUITE 102
ERIE PA
16507-1423
US

IV. Provider business mailing address

100 PEACH ST STE 102 SUITE 102
ERIE PA
16507-1423
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberOS018314
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: