Healthcare Provider Details

I. General information

NPI: 1023003613
Provider Name (Legal Business Name): MICHAEL C MACMILLAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12375 INDIAN PLACE DR
CHARLEVOIX MI
49720-9347
US

IV. Provider business mailing address

12375 INDIAN PLACE DR
CHARLEVOIX MI
49720-9347
US

V. Phone/Fax

Practice location:
  • Phone: 231-547-2496
  • Fax: 231-547-2823
Mailing address:
  • Phone: 231-547-2496
  • Fax: 231-547-2823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704113930
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: