Provider Demographics
NPI:1073604690
Name:MACMILLAN, PATRICK EDWARD (DO)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:EDWARD
Last Name:MACMILLAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-9357
Mailing Address - Country:US
Mailing Address - Phone:417-753-9404
Mailing Address - Fax:
Practice Address - Street 1:101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-9357
Practice Address - Country:US
Practice Address - Phone:417-753-9404
Practice Address - Fax:417-753-9137
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2H29207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26111OtherBLUE CROSS BLUE SHIELD
MO242498541Medicaid
MO242498541Medicaid
OH000003422Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER