1366645376 NPI number — MILLENNIUM MEDICAL MANAGEMENT LLC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366645376 NPI number — MILLENNIUM MEDICAL MANAGEMENT LLC

Employer Identification Number (EIN):

Provider Organization Name:

MILLENNIUM MEDICAL MANAGEMENT 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 Other Organization Name:

DEUK SPINE INSTITUTE, PRIMARY CARE OF BREVARD, INJURY TREATMENT GROUP

Provider Other Organization Name Type Code:

3

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:

1366645376

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

03/17/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

7955 SPYGLASS HILL RD STE A

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

MELBOURNE

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

32940-8249

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

321-255-6670

Provider Business Mailing Address Fax Number:

321-242-2545

Provider First Line Business Practice Location Address:

7955 SPYGLASS HILL RD STE A

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

MELBOURNE

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

32940-8249

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

321-255-6670

Provider Business Practice Location Address Fax Number:

321-242-2545

Provider Enumeration Date:

06/07/2007

Authorized Official Last Name:

DEUKMEDJIAN

Authorized Official First Name:

SUN

Authorized Official Middle Name:

MEE

Authorized Official Title or Position:

FINANCIAL OFFICER

Authorized Official Telephone Number:

321-775-1290

• Taxonomy code: 207Q00000X , with the licence number:  ME84856 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207T00000X , with the licence number: ME82061 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207X00000X , with the licence number: ME95180 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207XS0114X , with the licence number: ME95180 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208100000X , with the licence number: ME93866 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208100000X , with the licence number: ME111580 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208100000X , with the licence number: OS12589 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2081P2900X , with the licence number: ME93866 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2081P2900X , with the licence number: ME111580 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2081P2900X , with the licence number: OS12589 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2081S0010X , with the licence number: ME93866 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208VP0014X , with the licence number: ME93866 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208VP0014X , with the licence number: ME111580 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QM1200X , with the licence number: IAC ACCREDITED 7422 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363AS0400X , with the licence number: PA9105911 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 33435 . This is a "BCBSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 3612958 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: DG6510 . This is a "MEDICARE RAILROAD CARRIER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 613998300 . This is a "DOL ASC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 2921108 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 009717700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".