Provider Demographics
NPI:1295824738
Name:JEFFREY T MACMILLAN MD PA
Entity Type:Organization
Organization Name:JEFFREY T MACMILLAN MD PA
Other - Org Name:JEFFREY T MACMILLAN MD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MACMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-894-2121
Mailing Address - Street 1:9119 W 74TH ST
Mailing Address - Street 2:SUITE 354
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2215
Mailing Address - Country:US
Mailing Address - Phone:913-894-2121
Mailing Address - Fax:913-894-9592
Practice Address - Street 1:12200 W 106TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66215-2300
Practice Address - Country:US
Practice Address - Phone:913-894-2121
Practice Address - Fax:913-894-9592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-25519207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSDG2851OtherRR MEDICARE GROUP #
KS100171940AMedicaid
KS21793020OtherBCBS KC
KS200030413OtherMEDICARE RR
MO208162701Medicaid
MO208162701Medicaid
KS0007595Medicare ID - Type Unspecified
KS200030413OtherMEDICARE RR
KS111277Medicare PIN