Healthcare Provider Details

I. General information

NPI: 1730470493
Provider Name (Legal Business Name): MICHAEL RYAN MILLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14826 CLAYMORE
BLOOMINGTON IL
61705-1000
US

IV. Provider business mailing address

14826 CLAYMORE
BLOOMINGTON IL
61705-1000
US

V. Phone/Fax

Practice location:
  • Phone: 309-294-5649
  • Fax:
Mailing address:
  • Phone: 309-294-5649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041397136
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2009007215
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2011012309
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209009116
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: