Provider Demographics
NPI:1093261992
Name:MILLENNIUM ULTRASOUND LLC
Entity Type:Organization
Organization Name:MILLENNIUM ULTRASOUND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:
Authorized Official - Last Name:STARKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:RCIS,RCS
Authorized Official - Phone:219-895-9695
Mailing Address - Street 1:1149 POLK ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46407-1120
Mailing Address - Country:US
Mailing Address - Phone:219-487-5736
Mailing Address - Fax:
Practice Address - Street 1:1149 POLK ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46407-1120
Practice Address - Country:US
Practice Address - Phone:219-487-5736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN00039743246XS1301X, 2471S1302X, 2471V0105X, 246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Single Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN246XS1301XMedicare PIN
IN246X00000XMedicare PIN