Provider Demographics
NPI:1447210745
Name:MICELI, MATHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:
Last Name:MICELI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 AFFLINK PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-2289
Mailing Address - Country:US
Mailing Address - Phone:205-366-9740
Mailing Address - Fax:205-344-9992
Practice Address - Street 1:105 US HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732-3605
Practice Address - Country:US
Practice Address - Phone:334-287-2647
Practice Address - Fax:334-287-2405
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20438207RX0202X
AL31266207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02124094Medicaid
G04464Medicare UPIN
AL102I908364Medicare PIN
MS02124094Medicaid