Basic Information
| Provider Information | |||||||||
| NPI: | 1265468623 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENNIUM MEDICAL GROUP SOUTH PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25241 GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482401404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135383099 | ||||||||
| FaxNumber: | 3135383282 | ||||||||
| Practice Location | |||||||||
| Address1: | 9340 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481803362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132953388 | ||||||||
| FaxNumber: | 3132954198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 08/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | SLAIM | ||||||||
| AuthorizedOfficialFirstName: | ABRAHAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3135383099 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0902X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500H255490 | 01 | MI | BLUE SHIELD | OTHER | DD9487 | 01 | MI | MEDICARE ID TYPE UNSPECIFIED | OTHER | 700H222490 | 01 | MI | BLUE SHIELD GROUP | OTHER |