Provider Demographics
NPI:1396887063
Name:BRAD MCMILLIN INC
Entity type:Organization
Organization Name:BRAD MCMILLIN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACT REC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MCCUBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-242-4920
Mailing Address - Street 1:1415 W US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1618
Mailing Address - Country:US
Mailing Address - Phone:618-624-4471
Mailing Address - Fax:618-624-4496
Practice Address - Street 1:1415 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1618
Practice Address - Country:US
Practice Address - Phone:618-624-4471
Practice Address - Fax:618-624-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2023-7529332S00000X
IL3184237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8215212OtherBCBS OF ILLINOIS