Provider Demographics
NPI:1083734826
Name:MCMILLAN, KENNETH REED (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:REED
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5618 32ND AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2604
Mailing Address - Country:US
Mailing Address - Phone:763-533-1255
Mailing Address - Fax:
Practice Address - Street 1:2020 BLOOMINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3073
Practice Address - Country:US
Practice Address - Phone:612-813-1610
Practice Address - Fax:612-813-1612
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41394208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG95124Medicare UPIN