Provider Demographics
NPI:1669457677
Name:MILAM, THOMAS RICHERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RICHERSON
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 1:2752 JEFFERSON ST SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-3318
Mailing Address - Country:US
Mailing Address - Phone:540-795-2529
Mailing Address - Fax:
Practice Address - Street 1:2017 JEFFERSON ST SW FL 2
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2419
Practice Address - Country:US
Practice Address - Phone:910-616-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1871252084A0401X
MO20180327312084P0800X
WAMD608500872084P0800X
CAC1722442084P0800X
TXR64422084P0800X
MN636242084P0800X
WI115-3202084P0800X
VA01012268332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G95502Medicare UPIN