=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124104187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLER FAMILY MEDICINE CLINIC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 06/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 153 S COLLEGE ST
-----------------------------------------------------
City | HAMILTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31811-5306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-628-9980
-----------------------------------------------------
Fax | 706-628-7024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 325 153 S. COLLEGE ST.
-----------------------------------------------------
City | HAMILTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31811-0325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-628-9980
-----------------------------------------------------
Fax | 706-628-7024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | DR. ALAN BENNETT MILLER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 706-628-9980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 044022
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------