Individual
MARY E MILLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
200 E TYRANENA PARK RD, LAKE MILLS, WI 53551-9678
(920) 648-3113
(920) 648-3656
Mailing address
200 E TYRANENA PARK RD, LAKE MILLS, WI 53551-9678
(920) 648-3113
(920) 648-3656
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
4301070306
MI
207Q00000X
Family Medicine Physician
50074-020
WI
207Q00000X
Family Medicine Physician
Primary
50074-20
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
118658200
—
WY
05
—
34759800
—
WI
Enumeration date
11/08/2006
Last updated
07/31/2012
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