Basic Information
| Provider Information | |||||||||
| NPI: | 1104884949 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MS MILAM MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 SOUTH ANITA AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104159954 | ||||||||
| FaxNumber: | 3104766385 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 WILSHIRE BLVD | ||||||||
| Address2: | FLOOR 2 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102647300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILAM | ||||||||
| AuthorizedOfficialFirstName: | MALLORY | ||||||||
| AuthorizedOfficialMiddleName: | STANTON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3104159954 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A78479 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.