Provider Demographics
NPI:1124104187
Name:MILLER FAMILY MEDICINE CLINIC, P.C.
Entity type:Organization
Organization Name:MILLER FAMILY MEDICINE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:BENNETT
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-628-9980
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:153 S. COLLEGE ST.
Mailing Address - City:HAMILTON
Mailing Address - State:GA
Mailing Address - Zip Code:31811-0325
Mailing Address - Country:US
Mailing Address - Phone:706-628-9980
Mailing Address - Fax:706-628-7024
Practice Address - Street 1:153 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:GA
Practice Address - Zip Code:31811-5306
Practice Address - Country:US
Practice Address - Phone:706-628-9980
Practice Address - Fax:706-628-7024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00762319HMedicaid
GA00762319HMedicaid
GAF20997Medicare UPIN