Basic Information
| Provider Information | |||||||||
| NPI: | 1558470328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILAN SOSNOVEC, MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3439 NE SANDY BLVD | ||||||||
| Address2: | PMB 375 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032848841 | ||||||||
| FaxNumber: | 5032823302 | ||||||||
| Practice Location | |||||||||
| Address1: | 12250 SW 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970052828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032926238 | ||||||||
| FaxNumber: | 5036010049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 10/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | SOSNOVEC | ||||||||
| AuthorizedOfficialFirstName: | MILAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5032848841 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD10928 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 184747 | 05 | OR | MEDICAID |