Basic Information
| Provider Information | |||||||||
| NPI: | 1881628550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLS | ||||||||
| FirstName: | EVELYN | ||||||||
| MiddleName: | MOORE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLS | ||||||||
| OtherFirstName: | EVELYN | ||||||||
| OtherMiddleName: | B | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 ILLINOIS AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544813114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153465000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 ILLINOIS AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENS POINT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544813114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153465000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036.142223 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 240152 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 18169-875 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1881628550 | 01 | NY | BCBS NY EXCELLUS | OTHER | 204491209 | 01 | NY | BLUE SHIELD | OTHER | 02779697 | 05 | NY | MEDICAID |