Provider Demographics
NPI:1376525741
Name:MILAM, PHILLIP EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:EDWARD
Last Name:MILAM
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: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
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA143070OtherLABOR & INDUSTRIES
WA8269995Medicaid
WAF78363Medicare UPIN
WA143070OtherLABOR & INDUSTRIES