Provider Demographics
NPI:1831162668
Name:MILLER, ELIZABETH S
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:S
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MAPLE AVE
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8475
Mailing Address - Country:US
Mailing Address - Phone:262-928-1900
Mailing Address - Fax:262-363-1949
Practice Address - Street 1:240 MAPLE AVE
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-8475
Practice Address - Country:US
Practice Address - Phone:262-928-1900
Practice Address - Fax:262-363-1949
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33568207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32129800Medicaid
WIG05693Medicare UPIN
683750649Medicare PIN