Provider Demographics
NPI:1356411292
Name:MILLER, MARY E (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E TYRANENA PARK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-9678
Mailing Address - Country:US
Mailing Address - Phone:920-648-3113
Mailing Address - Fax:920-648-3656
Practice Address - Street 1:200 E TYRANENA PARK RD
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-9678
Practice Address - Country:US
Practice Address - Phone:920-648-3113
Practice Address - Fax:920-648-3656
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070306207Q00000X
WI50074-020207Q00000X
WI50074-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34759800Medicaid
WY118658200Medicaid
WI007430345Medicare PIN
MIH14794Medicare UPIN
WY9744Medicare ID - Type Unspecified