=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174834659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERSON T. MILEY, M.D.,P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2010
-----------------------------------------------------
Last Update Date | 11/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12180 N MOPAC EXPY STE B
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-617-6767
-----------------------------------------------------
Fax | 512-617-5598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12180 N MOPAC EXPY STE B
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-617-6767
-----------------------------------------------------
Fax | 512-617-5598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFERSON THAYER MILEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 512-617-6767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | N5870
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084V0102X
-----------------------------------------------------
Taxonomy Name | Vascular Neurology Physician
-----------------------------------------------------
License Number | N5870
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 103329
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------