Basic Information
| Provider Information | |||||||||
| NPI: | 1841449832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILAM | ||||||||
| FirstName: | KRISTAN | ||||||||
| MiddleName: | ADEAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 E CHESTNUT ST | ||||||||
| Address2: | STE #310 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025896788 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 E CHESTNUT ST | ||||||||
| Address2: | STE #310 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402025700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025896788 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 11/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | TP806 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 44324 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100132420 | 05 | KY | MEDICAID |