1235188772 NPI number — DR. RICHARD STAYTON MILES MD

Table of content: DR. RICHARD STAYTON MILES MD (NPI 1235188772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235188772 NPI number — DR. RICHARD STAYTON MILES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILES
Provider First Name:
RICHARD
Provider Middle Name:
STAYTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235188772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 DOWELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSSELL SPRINGS
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42642-4278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-866-2440
Provider Business Mailing Address Fax Number:
270-866-2442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 DOWELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELL SPRINGS
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42642-4278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-866-2440
Provider Business Practice Location Address Fax Number:
270-866-2442
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  19700 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 080189178 . This is a "PALMETTO GBA RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0000000047852 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64197007 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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