Provider Demographics
NPI:1760626113
Name:MCMILLIAN, KELLY LYLES (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYLES
Last Name:MCMILLIAN
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 1:101 EAGLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5319
Mailing Address - Country:US
Mailing Address - Phone:205-995-1004
Mailing Address - Fax:205-991-6075
Practice Address - Street 1:101 EAGLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-5319
Practice Address - Country:US
Practice Address - Phone:205-995-1004
Practice Address - Fax:205-991-6075
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30655208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
511-23313OtherBCBS OF ALABAMA
AL000137515Medicaid