Provider Demographics
NPI:1861451221
Name:MCMILLAN, MARY S (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:VANTASSEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-775-4800
Mailing Address - Fax:612-775-4801
Practice Address - Street 1:10705 TOWN SQUARE DR NE STE 100
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-8185
Practice Address - Country:US
Practice Address - Phone:763-236-5400
Practice Address - Fax:763-236-5350
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40497207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN251327700Medicaid
MN251327700Medicaid
G37367Medicare UPIN