Healthcare Provider Details

I. General information

NPI: 1033869292
Provider Name (Legal Business Name): RYAN JACOB MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W BARAGA AVE
MARQUETTE MI
49855-4550
US

IV. Provider business mailing address

850 W BARAGA AVE
MARQUETTE MI
49855-4550
US

V. Phone/Fax

Practice location:
  • Phone: 906-449-3560
  • Fax:
Mailing address:
  • Phone: 906-449-3560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301513462
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: