1629585906 NPI number — MILLENIUM MEDICAL GROUP CORP.

Table of content: (NPI 1629585906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629585906 NPI number — MILLENIUM MEDICAL GROUP CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLENIUM MEDICAL GROUP CORP.
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:
MILLENIUM MEDICAL 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 Information

NPI Number:
1629585906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2740 SW 97TH AVE STE A-111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33165-2681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-332-4330
Provider Business Mailing Address Fax Number:
786-332-4109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2740 SW 97TH AVE
Provider Second Line Business Practice Location Address:
SUITE NUMBER A-111
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33165-3316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-332-4330
Provider Business Practice Location Address Fax Number:
786-332-4109
Provider Enumeration Date:
01/08/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SUAREZ
Authorized Official First Name:
DAMARYS
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
305-613-0798

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  ARNP9227984 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: MA64254 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 102931600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".