Provider Demographics
NPI:1699713685
Name:MALCOLM KEITH MILLER, MD
Entity type:Organization
Organization Name:MALCOLM KEITH MILLER, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-462-0975
Mailing Address - Street 1:PO BOX 7704
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:448 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2804
Practice Address - Country:US
Practice Address - Phone:800-462-0975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21020574Medicaid
COC522148Medicare PIN