Basic Information
| Provider Information | |||||||||
| NPI: | 1811122880 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENNIUM PHYSICIAN GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE STE 200 | ||||||||
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| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992612 | ||||||||
| Practice Location | |||||||||
| Address1: | 6321 DANIELS PKWY | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339124773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2009 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | HALTIGAN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR REVENUE CYCLE MNGMT | ||||||||
| AuthorizedOfficialTelephone: | 8778563774 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 261QR0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 207QA0505X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
No ID Information.