Basic Information
| Provider Information | |||||||||
| NPI: | 1982270526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENIAL MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 CALLE GRAN BRETANA | ||||||||
| Address2: | |||||||||
| City: | SAN GERMAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006833517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874773507 | ||||||||
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| Practice Location | |||||||||
| Address1: | 199 CALLE GRAN BRETANA | ||||||||
| Address2: | |||||||||
| City: | SAN GERMAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006833517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874773507 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2021 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7874773507 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD, MHA | ||||||||
| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.