Basic Information
| Provider Information | |||||||||
| NPI: | 1295758365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACMILLAN | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9119 W 74TH ST | ||||||||
| Address2: | SUITE 354 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662042215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138942121 | ||||||||
| FaxNumber: | 9138949592 | ||||||||
| Practice Location | |||||||||
| Address1: | 9119 W 74TH ST | ||||||||
| Address2: | SUITE 354 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662042215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138942121 | ||||||||
| FaxNumber: | 9138949592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 10/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 04-25519 | KS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100171940A | 05 | KS | MEDICAID | 431793993 | 01 | KS | TRIWEST | OTHER | 141094900 | 01 | KS | US DEPARTMENT OF LABOR | OTHER | 200030413 | 01 | KS | RR MEDICARE | OTHER | 208162701 | 05 | MO | MEDICAID | 15076140 | 01 | KS | HUMANA | OTHER | 21793010 | 01 | KS | BCBS KC | OTHER | 0982140 | 01 | KS | UNITED HEALTHCARE | OTHER |