Provider Demographics
NPI:1962543496
Name:MILLER, KENNETH ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ANDREW
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SHERMAN AVE E
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1960
Mailing Address - Country:US
Mailing Address - Phone:920-568-6090
Mailing Address - Fax:920-568-6083
Practice Address - Street 1:611 SHERMAN AVE E
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1960
Practice Address - Country:US
Practice Address - Phone:920-568-6090
Practice Address - Fax:920-568-6083
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11253504-1205208M00000X
IDM-13495208M00000X
WI29654207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962543496Medicaid
WI301250126Medicare PIN
WIF04281Medicare UPIN