Healthcare Provider Details

I. General information

NPI: 1962543496
Provider Name (Legal Business Name): KENNETH ANDREW MILLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 SHERMAN AVE E
FORT ATKINSON WI
53538-1960
US

IV. Provider business mailing address

611 SHERMAN AVE E
FORT ATKINSON WI
53538-1960
US

V. Phone/Fax

Practice location:
  • Phone: 920-568-6090
  • Fax: 920-568-6083
Mailing address:
  • Phone: 920-568-6090
  • Fax: 920-568-6083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29654
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number11253504-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM-13495
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: