Provider Demographics
NPI:1184678815
Name:MCCRILLIS, JOHN M
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:MCCRILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3935 DUPONT CIR
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4824
Mailing Address - Country:US
Mailing Address - Phone:502-458-7476
Mailing Address - Fax:502-458-7797
Practice Address - Street 1:3935 DUPONT CIR
Practice Address - Street 2:SUITE C
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4824
Practice Address - Country:US
Practice Address - Phone:502-458-7476
Practice Address - Fax:502-458-7797
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46121223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000068357OtherANTHEM NON-PAR
KYU65556Medicare UPIN
KY5003340001Medicare NSC
KY1647201Medicare ID - Type UnspecifiedMEDICARE PART B