Provider Demographics
NPI:1174522270
Name:MILLER, RUSSELL PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:PAUL
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 1:121 BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:PATTON
Mailing Address - State:PA
Mailing Address - Zip Code:16668-1017
Mailing Address - Country:US
Mailing Address - Phone:814-674-5225
Mailing Address - Fax:814-674-2338
Practice Address - Street 1:121 BEECH AVE
Practice Address - Street 2:
Practice Address - City:PATTON
Practice Address - State:PA
Practice Address - Zip Code:16668-1017
Practice Address - Country:US
Practice Address - Phone:814-674-5225
Practice Address - Fax:814-674-2338
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060029L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016115020008Medicaid
PA067608Medicare ID - Type Unspecified
PA0016115020008Medicaid