Basic Information
| Provider Information | |||||||||
| NPI: | 1518639665 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENNIUM PHYSICIAN GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE FL 2 | ||||||||
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| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992612 | ||||||||
| Practice Location | |||||||||
| Address1: | 15416 N FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336131244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137235450 | ||||||||
| FaxNumber: | 8137235451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2021 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | HALTIGAN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 8778563774 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.