Provider Demographics
NPI:1114912037
Name:SALLIS, MILTON (MD)
Entity Type:Individual
Prefix:
First Name:MILTON
Middle Name:
Last Name:SALLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 DINSMOOR DR
Mailing Address - Street 2:CHESTERFIELD
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2956
Mailing Address - Country:US
Mailing Address - Phone:314-583-9142
Mailing Address - Fax:
Practice Address - Street 1:378 DINSMOOR DR
Practice Address - Street 2:CHESTERFIELD
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2956
Practice Address - Country:US
Practice Address - Phone:314-583-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-109941207P00000X
MO020415207R00000X
MO2002020415207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207673021Medicaid
MO207673005Medicaid
MO207673013Medicaid
IL$$$$$$$$$-6Medicaid
IL$$$$$$$$$Medicaid
IL$$$$$$$$$-4Medicaid
MO207673005Medicaid
MO030013212Medicare PIN
IL$$$$$$$$$-5Medicaid
IL$$$$$$$$$-6Medicaid
MOH77395Medicare UPIN
MO207673005Medicaid
MO908374748Medicare PIN
MO207673013Medicaid
MO207673021Medicaid