Provider Demographics
NPI:1255915039
Name:MILLER, KEVIN M
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 MICHELLE RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21102-1757
Mailing Address - Country:US
Mailing Address - Phone:443-536-1638
Mailing Address - Fax:
Practice Address - Street 1:10700 CHARTER DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3629
Practice Address - Country:US
Practice Address - Phone:410-910-2351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3895225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant