Healthcare Provider Details

I. General information

NPI: 1699155333
Provider Name (Legal Business Name): HENRY JACKSON MILLER III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MEDICAL PARK, STE 400 PEDIATRIC OUTPATIENT CENTER
COLUMBIA SC
29203
US

IV. Provider business mailing address

14 MEDICAL PARK, STE 400 PEDIATRIC OUTPATIENT CENTER
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6155
  • Fax: 803-434-6979
Mailing address:
  • Phone: 803-434-6155
  • Fax: 803-434-6979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL38345
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: