Healthcare Provider Details

I. General information

NPI: 1871580654
Provider Name (Legal Business Name): RUEL T MICIANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 THUNDERBIRD DR
HARRISONVILLE MO
64701-1558
US

IV. Provider business mailing address

702 THUNDERBIRD DR
HARRISONVILLE MO
64701-1558
US

V. Phone/Fax

Practice location:
  • Phone: 816-380-4040
  • Fax:
Mailing address:
  • Phone: 816-380-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33300
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: