Basic Information
| Provider Information | |||||||||
| NPI: | 1063487999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PALMETTO HEALTH PKWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292121759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039077300 | ||||||||
| FaxNumber: | 8039077309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 238086-1 | NY | N | Other Service Providers | Specialist | 174400000X | 042193 | CT | N | Other Service Providers | Specialist | 174400000X | MD431754 | PA | N | Other Service Providers | Specialist | 207V00000X | 2008-00751 | NC | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 33386 | SC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 060870439 | 01 | CT | PHCS | OTHER | 5315574 | 01 | CT | AETNA | OTHER | 060870439 | 01 | CT | EMPIRE BCBS | OTHER | CV8825 | 01 | CT | HEALTHNET | OTHER | N51009 | 05 | SC | MEDICAID | 060870439 | 01 | CT | POMCO | OTHER | 042193 | 01 | CT | CONNECTICARE | OTHER | 060870439 | 01 | CT | CIGNA | OTHER | 010042193CT01 | 01 | CT | ANTHEM BCBS OF CT | OTHER | P3306236 | 01 | CT | OXFORD | OTHER |