1477642239 NPI number — MICHAEL D MCMILLAN PHD

Table of content: MICHAEL D MCMILLAN PHD (NPI 1477642239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477642239 NPI number — MICHAEL D MCMILLAN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCMILLAN
Provider First Name:
MICHAEL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477642239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43800 GARFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON TWP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48038-1136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-343-3481
Provider Business Mailing Address Fax Number:
313-343-7937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22201 MOROSS RD
Provider Second Line Business Practice Location Address:
270
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48236-2169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-343-3481
Provider Business Practice Location Address Fax Number:
313-343-7937
Provider Enumeration Date:
10/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X , with the licence number:  6301002599 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0H208910 . This is a "BLUE CROSS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0H260650 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".