Healthcare Provider Details

I. General information

NPI: 1679743603
Provider Name (Legal Business Name): WILLIAM M MILAM MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 NORTH JACKSON STREET
TULLAHOMA TN
37388
US

IV. Provider business mailing address

1970 NORTH JACKSON STREET P O BOX 1147
TULLAHOMA TN
37388
US

V. Phone/Fax

Practice location:
  • Phone: 931-455-3399
  • Fax: 931-455-1806
Mailing address:
  • Phone: 931-455-3399
  • Fax: 931-455-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMD000009974
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMN1186875
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD0000009974
License Number StateTN

VIII. Authorized Official

Name: DR. WILLIAM M MILAM
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 931-455-3399