Provider Demographics
NPI:1730388083
Name:MILLER, TIMOTHY EDWARD (PT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:MILLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 MORRISON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-3847
Mailing Address - Country:US
Mailing Address - Phone:608-835-3535
Mailing Address - Fax:
Practice Address - Street 1:354 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-1426
Practice Address - Country:US
Practice Address - Phone:608-835-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10513-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36112200Medicaid