Basic Information
| Provider Information | |||||||||
| NPI: | 1023444874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENNIUM PHYSICIAN GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3434 HANCOCK BRIDGE PKWY | ||||||||
| Address2: | |||||||||
| City: | N FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992625 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 8TH ST N | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392615511 | ||||||||
| FaxNumber: | 2396493301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2013 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | TETER | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR REVENUE CYCLE MNGMT | ||||||||
| AuthorizedOfficialTelephone: | 8556747400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 6953950001 | 01 | FL | MEDICARE NSC | OTHER |