Provider Demographics
NPI:1548264153
Name:MILLER, NELSON
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12307-1508
Mailing Address - Country:US
Mailing Address - Phone:518-374-5353
Mailing Address - Fax:
Practice Address - Street 1:1040 STATE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12307-1508
Practice Address - Country:US
Practice Address - Phone:518-374-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131823174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000416190002OtherBLUE SHIELD
NY040426007600OtherFIDELIS
NY10001377OtherCDPHP
NY15155OtherMVP
NY39D201OtherBLUE CROSS
NY160012995OtherRAILROAD MEDICARE
NY00486571Medicaid
NY15155OtherMVP
NY160012995OtherRAILROAD MEDICARE