MEDICARE: SALLIE CAROLINE MILLER PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	160002755	IL

General Provider Information

NPI Number	:	1326489253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLIE CAROLINE MILLER PTA

Provider Business Mailing Address
First Line	:	424 S 23RD ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62226-7541
Country	:	US
Telephone Number	:	618-960-6904
Fax Number	:

Provider Business Practice Location Address
First Line	:	12801 N CENTRAL EXPY
Second Line	:	SUITE 1750
City	:	DALLAS
State	:	TX
Zip	:	75243-1716
Country	:	US
Telephone Number	:	877-293-6287
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2013
Last Update Date	:	07/08/2013

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