1043466790 NPI number — BRAD MCMILLIN INC

Table of content: (NPI 1043466790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043466790 NPI number — BRAD MCMILLIN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAD MCMILLIN INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1043466790
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1415 WEST HIGHWAY 50
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O'FALLON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-624-4471
Provider Business Mailing Address Fax Number:
618-624-4496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3142 NAMEOKI RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANITE CITY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62040-5013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-451-1900
Provider Business Practice Location Address Fax Number:
618-451-1918
Provider Enumeration Date:
08/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MCCUBBINS
Authorized Official First Name:
PATTY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ACCOUNTS RECEIVABLE
Authorized Official Telephone Number:
618-624-4471

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X , with the licence number:  IL 2792 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8215212 . This is a "BLUE CROSS BLUESHIELD OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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