Provider Demographics
NPI:1093287377
Name:MILLENIUM MEDICAL GROUP CORP.
Entity Type:Organization
Organization Name:MILLENIUM MEDICAL GROUP CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-332-4330
Mailing Address - Street 1:2720 SW 97TH AVE STE C105
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2677
Mailing Address - Country:US
Mailing Address - Phone:786-332-4330
Mailing Address - Fax:786-332-4109
Practice Address - Street 1:2720 SW 97TH AVE STE C105
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2677
Practice Address - Country:US
Practice Address - Phone:786-332-4330
Practice Address - Fax:786-332-4109
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023735400Medicaid