MEDICARE: BRAD MCMILLIN INC

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	332S00000X	Hearing Aid Equipment	IL 2792	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8215212	OTHER	IL	BLUE CROSS BLUESHIELD OF IL

General Provider Information

NPI Number	:	1043466790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAD MCMILLIN INC

Provider Business Mailing Address
First Line	:	1415 WEST HIGHWAY 50
Second Line	:
City	:	O'FALLON
State	:	IL
Zip	:	62269
Country	:	US
Telephone Number	:	618-624-4471
Fax Number	:	618-624-4496

Provider Business Practice Location Address
First Line	:	3142 NAMEOKI RD
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-5013
Country	:	US
Telephone Number	:	618-451-1900
Fax Number	:	618-451-1918

Authorized Official
Title or Position	:	ACCOUNTS RECEIVABLE
Name	:	MRS. PATTY L MCCUBBINS
Credential	:
Telephone Number	:	618-624-4471

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	04/24/2009

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Directions to “BRAD MCMILLIN INC ” Practice Location

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