Provider Demographics
NPI:1194746180
Name:CHARLES E MILLER OD SC
Entity type:Organization
Organization Name:CHARLES E MILLER OD SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-387-6397
Mailing Address - Street 1:605 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-4519
Mailing Address - Country:US
Mailing Address - Phone:715-387-6397
Mailing Address - Fax:715-384-6140
Practice Address - Street 1:605 E 4TH ST
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-4519
Practice Address - Country:US
Practice Address - Phone:715-387-6397
Practice Address - Fax:715-384-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38705100Medicaid
WIU20485Medicare UPIN
WI0759150001Medicare NSC
WI38705100Medicaid