Healthcare Provider Details

I. General information

NPI: 1366492639
Provider Name (Legal Business Name): CHARLES G MILLER II DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LOVE ST
ERWIN TN
37650-1734
US

IV. Provider business mailing address

500 LOVE ST
ERWIN TN
37650-1734
US

V. Phone/Fax

Practice location:
  • Phone: 423-735-4160
  • Fax: 423-735-4159
Mailing address:
  • Phone: 423-735-4160
  • Fax: 423-735-4159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO0000001740
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: