Healthcare Provider Details

I. General information

NPI: 1659689677
Provider Name (Legal Business Name): DR. MARCELLUS RYAN LUWIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5514 CORPORATE DR STE 120
SAINT JOSEPH MO
64507-7754
US

IV. Provider business mailing address

5514 CORPORATE DR STE 120
SAINT JOSEPH MO
64507-7754
US

V. Phone/Fax

Practice location:
  • Phone: 816-271-1350
  • Fax: 816-271-8810
Mailing address:
  • Phone: 816-271-1350
  • Fax: 816-271-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9409951
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019019525
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: