Loren    Miller    DPM
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004198
NPI
1285682344
Tax ID
592766269
Effective Date
4/1/2012
Last Updated
10/1/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
4167 5th Avenue North
Saint Petersburg, FL 33713
United States
County
Pinellas
Phone
7273213100 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Podiatry
Map
Address