Provider Demographics
NPI:1154547263
Name:BRAD MCMILLIN, INC
Entity type:Organization
Organization Name:BRAD MCMILLIN, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCUBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-624-4471
Mailing Address - Street 1:1415 WEST HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-624-4471
Mailing Address - Fax:618-624-4496
Practice Address - Street 1:1131 N KINGSHIGHWAY ST
Practice Address - Street 2:SUITE E
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-3504
Practice Address - Country:US
Practice Address - Phone:573-335-3714
Practice Address - Fax:573-335-3749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO154857OtherBC BS OF MISSOURI
IL8215212OtherBC BS OF ILLINOIS