Healthcare Provider Details

I. General information

NPI: 1447210745
Provider Name (Legal Business Name): MATHEW MICELI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 US HIGHWAY 80 E
DEMOPOLIS AL
36732-3605
US

IV. Provider business mailing address

1400 AFFLINK PL SUITE 100
TUSCALOOSA AL
35406-2289
US

V. Phone/Fax

Practice location:
  • Phone: 334-287-2647
  • Fax: 334-287-2405
Mailing address:
  • Phone: 205-366-9740
  • Fax: 205-344-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number20438
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number31266
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: