Provider Demographics
NPI:1124217377
Name:SNO-VALLEY FAMILY MEDICINE
Entity Type:Organization
Organization Name:SNO-VALLEY FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MILAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-788-2490
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-0516
Mailing Address - Country:US
Mailing Address - Phone:425-788-2490
Mailing Address - Fax:425-788-2462
Practice Address - Street 1:15602 MAIN ST NE
Practice Address - Street 2:200
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019
Practice Address - Country:US
Practice Address - Phone:425-788-2490
Practice Address - Fax:425-788-2462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039262261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
F78363Medicare UPIN