Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207V00000X | Obstetrician & Gynecologist | 036-108046 | IL |
Y | 207VF0040X | Female Pelvic Medicine and Reconstructive Surgeon | 036-108046 | IL |
NPI | 1003915968 |
---|---|
Provider Name | Jay James Miller |
First Address | Bloomington, IL 61701 |
Second Address | Bloomington, IL 61701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2006 |
Last Update Date | 03/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I06275 | (02) | IL |