=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487642070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY LYNN MILLER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 COMMERCIAL RD
-----------------------------------------------------
City | LEOMINSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01453-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-435-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 PATRICK HENRY CIR
-----------------------------------------------------
City | ACTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01720-2134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-263-1909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 40168
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------