1497971501 NPI number — BRAD MCMILLIN, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497971501 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:
1497971501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2009
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:
3119 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002-5473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-463-9490
Provider Business Practice Location Address Fax Number:
618-463-9491
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X ; 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 BLUE SHIELD IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 154857 . This is a "BLUE CROSS BLUE SHIELD MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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