Healthcare Provider Details

I. General information

NPI: 1235663147
Provider Name (Legal Business Name): ROSS F MICCICHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E BROADWAY STE 270
LOUISVILLE KY
40202-2040
US

IV. Provider business mailing address

500 S PRESTON ST RM 305
LOUISVILLE KY
40202-1702
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-4740
  • Fax:
Mailing address:
  • Phone: 502-852-8696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number58926
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01092561A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: