=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710764212
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL THOMAS MILLER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2023
-----------------------------------------------------
Last Update Date | 09/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1750 W SW 59TH ST
-----------------------------------------------------
City | MUSTANG
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73064-2298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-802-4746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1750 W SW 59TH ST
-----------------------------------------------------
City | MUSTANG
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73064-2298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-802-4746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------