Healthcare Provider Details

I. General information

NPI: 1619062056
Provider Name (Legal Business Name): MICHAEL J. MILNE M.D., L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S KIRKWOOD RD SUITE 203
ST. LOUIS MO
63122
US

IV. Provider business mailing address

P.O. BOX 504871
ST. LOUIS MO
63150
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-6075
  • Fax: 314-821-8377
Mailing address:
  • Phone: 314-966-6075
  • Fax: 314-821-8377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number2003014166
License Number StateMO

VIII. Authorized Official

Name: DR. MICHAEL J. MILNE
Title or Position: OWNER
Credential: M.D.
Phone: 314-966-6075