Basic Information
| Provider Information | |||||||||
| NPI: | 1477701969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLS MEDICAL PRACTICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26110 EMERY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | WARRENSVILLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441285788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403593429 | ||||||||
| FaxNumber: | 4403686866 | ||||||||
| Practice Location | |||||||||
| Address1: | 26110 EMERY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | WARRENSVILLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441285788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403593429 | ||||||||
| FaxNumber: | 4403686866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 07/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHOBREY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5026307249 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 35083334 | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 3072482 | 05 | OH | MEDICAID |