Provider Demographics
NPI:1841278306
Name:VAN HISE, MILTON LOWELL (MD)
Entity type:Individual
Prefix:DR
First Name:MILTON
Middle Name:LOWELL
Last Name:VAN HISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000384952085N0700X, 2085R0202X
IDM-123792085N0700X, 2085R0202X
AKMEDS80102085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1017174Medicaid
WA135652OtherL&I PROVIDER NUMBER
WA135577OtherL&I PROVIDER NUMBER
ID1841278306Medicaid
WA175556OtherL&I PROVIDER NUMBER
WA204122OtherL & I PROVIDER NUMBER
WA8255234Medicaid
WA154345OtherL&I PROVIDER NUMBER
WA8862880Medicare PIN
WA154345OtherL&I PROVIDER NUMBER
WAGAB25169Medicare PIN
WA300125391Medicare UPIN
WA135577OtherL&I PROVIDER NUMBER
ID1841278306Medicaid
ID20005722Medicare PIN
WAGAB15101Medicare PIN
WAH13630Medicare UPIN
WA175556OtherL&I PROVIDER NUMBER
WAP00225047Medicare PIN
WA300113231Medicare PIN