MEDICARE: MICHAEL MCMILLAN ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	358	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	358	OTHER	NM	STATE LICENSE

General Provider Information

NPI Number	:	1700886025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL MCMILLAN ATC

Provider Business Mailing Address
First Line	:	1268 E 32ND ST
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88061-7229
Country	:	US
Telephone Number	:	575-534-1919
Fax Number	:	575-534-0135

Provider Business Practice Location Address
First Line	:	1268 E 32ND ST
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88061-7229
Country	:	US
Telephone Number	:	575-534-1919
Fax Number	:	575-534-0135

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	03/02/2009

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