Provider Demographics
NPI:1801061601
Name:BRENDAN M. MILES
Entity type:Organization
Organization Name:BRENDAN M. MILES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:MATHEW
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-256-5807
Mailing Address - Street 1:411B MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-4221
Mailing Address - Country:US
Mailing Address - Phone:662-256-5807
Mailing Address - Fax:662-256-3729
Practice Address - Street 1:411B MAIN ST S
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-4221
Practice Address - Country:US
Practice Address - Phone:662-256-5807
Practice Address - Fax:662-256-3729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08217261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0013573Medicaid
AL009941165Medicaid
AL009941165Medicaid
MS0013573Medicaid
MS300000038Medicare PIN