Provider Demographics
NPI:1114903630
Name:MACMILLAN, KELLY M (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:MACMILLAN
Suffix:
Gender:F
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:C/O ST MARY'S HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8695
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:168 KINSLEY ST STE 20
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3634
Practice Address - Country:US
Practice Address - Phone:603-883-3365
Practice Address - Fax:603-883-5758
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11599207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3076899Medicaid
NHG49987Medicare UPIN