Healthcare Provider Details

I. General information

NPI: 1881808061
Provider Name (Legal Business Name): JACOB BENJAMIN MILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NE SAINT LUKES BLVD
LEES SUMMIT MO
64086-6000
US

IV. Provider business mailing address

PO BOX 412431
KANSAS CITY MO
64141-2431
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-5097
  • Fax: 816-347-5045
Mailing address:
  • Phone: 913-647-4100
  • Fax: 913-258-2509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2011012600
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: