Provider Demographics
NPI:1023003613
Name:MACMILLAN, MICHAEL C (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:MACMILLAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:12375 INDIAN PLACE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-9347
Mailing Address - Country:US
Mailing Address - Phone:231-547-2496
Mailing Address - Fax:231-547-2823
Practice Address - Street 1:12375 INDIAN PLACE DR
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-9347
Practice Address - Country:US
Practice Address - Phone:231-547-2496
Practice Address - Fax:231-547-2823
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704113930367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered