Basic Information
| Provider Information | |||||||||
| NPI: | 1720135775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 MARCUS AVENUE | ||||||||
| Address2: | |||||||||
| City: | LAKE SUCCESS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166226000 | ||||||||
| FaxNumber: | 5166292027 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 N. BROADWAY | ||||||||
| Address2: | |||||||||
| City: | JERICHO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165975070 | ||||||||
| FaxNumber: | 5165975067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 04/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 182624 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01600646 | 05 | NY | MEDICAID |