1225700974 NPI number — MILLENNIUM PHYSICIAN GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225700974 NPI number — MILLENNIUM PHYSICIAN GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLENNIUM PHYSICIAN GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225700974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2675 WINKLER AVE FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33901-9342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-856-3774
Provider Business Mailing Address Fax Number:
239-599-2612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3360 COUNTY ROAD 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLEBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32068-4359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-291-2221
Provider Business Practice Location Address Fax Number:
904-291-9192
Provider Enumeration Date:
10/01/2021

Additional Information

Authorized Official

Authorized Official Last Name:
HALTIGAN
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF REVENUE CYCLE
Authorized Official Telephone Number:
877-856-3774

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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