MEDICARE: JEREMY WILSON MILLER PT, DPT

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	225100000X	Physical Therapist	PT60742902	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G8968027	OTHER	WA	MEDICARE
2	1912436445	OTHER	WA	MEDICARE

General Provider Information

NPI Number	:	1912436445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY WILSON MILLER PT, DPT

Provider Business Mailing Address
First Line	:	16083 SW UPPER BOONES FERRY RD STE 300
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97224-7736
Country	:	US
Telephone Number	:	800-219-8835
Fax Number	:	503-639-9699

Provider Business Practice Location Address
First Line	:	3121 E MADISON ST STE 201
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-4259
Country	:	US
Telephone Number	:	206-324-5389
Fax Number	:	206-324-5391

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

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	07/31/2017

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