Provider Demographics
NPI:1598052813
Name:MCILMOIL, STEPHEN ANDREW (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ANDREW
Last Name:MCILMOIL
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:PO BOX 3290
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-7290
Mailing Address - Country:US
Mailing Address - Phone:541-963-8421
Mailing Address - Fax:541-963-1476
Practice Address - Street 1:900 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1387
Practice Address - Country:US
Practice Address - Phone:541-963-8421
Practice Address - Fax:541-963-1476
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019465207PE0004X
ORDO166905207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500674427Medicaid