Provider Demographics
NPI:1992715122
Name:MILLER, KENNETH L (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:SMITH IMAGING INC
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640
Mailing Address - Country:US
Mailing Address - Phone:573-760-8075
Mailing Address - Fax:314-821-2180
Practice Address - Street 1:1101 W LIBERTY
Practice Address - Street 2:PARKLAND HEALTH CENTER DEPT OF RADIOLOGY
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-760-8075
Practice Address - Fax:573-760-8358
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-11-26
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Provider Licenses
StateLicense IDTaxonomies
MO1099722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
109972OtherLICENSE NUMBER
8707OtherHEALTHCARE
945K1OtherMO BLUE
14989V14989OtherGHP
290568OtherCMR
290568OtherHL
G23727OtherNATIONAL REGISTRY NUMBER
290568OtherAMER MEDSE
MO945K1OtherBCBS MO
945K1OtherIL BLUE
STL1600408OtherUHC
MO945K1OtherBCBS MO