Healthcare Provider Details

I. General information

NPI: 1396127569
Provider Name (Legal Business Name): JACK PARKER MILLER JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 TIGER BLVD
CLEMSON SC
29631-1480
US

IV. Provider business mailing address

PO BOX 100174
COLUMBIA SC
29202-3174
US

V. Phone/Fax

Practice location:
  • Phone: 864-512-7257
  • Fax: 864-654-7672
Mailing address:
  • Phone: 864-512-7257
  • Fax: 864-654-7672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL38346
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38346
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: