Provider Demographics
NPI:1366645376
Name:MILLENNIUM MEDICAL MANAGEMENT LLC
Entity Type:Organization
Organization Name:MILLENNIUM MEDICAL MANAGEMENT LLC
Other - Org Name:DEUK SPINE INSTITUTE, PRIMARY CARE OF BREVARD, INJURY TREATMENT GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUN
Authorized Official - Middle Name:MEE
Authorized Official - Last Name:DEUKMEDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-775-1290
Mailing Address - Street 1:7955 SPYGLASS HILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8249
Mailing Address - Country:US
Mailing Address - Phone:321-255-6670
Mailing Address - Fax:321-242-2545
Practice Address - Street 1:7955 SPYGLASS HILL RD STE A
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8249
Practice Address - Country:US
Practice Address - Phone:321-255-6670
Practice Address - Fax:321-242-2545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84856207Q00000X
FLME82061207T00000X
FLME95180207X00000X, 207XS0114X
FLME93866208100000X, 2081P2900X, 2081S0010X, 208VP0014X
FLME111580208100000X, 2081P2900X, 208VP0014X
FLOS12589208100000X, 2081P2900X
FLIAC ACCREDITED 7422261QM1200X
FLPA9105911363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33435OtherBCBSFL
FL3612958OtherAETNA
FLDG6510OtherMEDICARE RAILROAD CARRIER
FL613998300OtherDOL ASC
FL2921108OtherCIGNA
FL=========OtherTAX ID NUMBER
FLAF103Medicare PIN
FL33435OtherBCBSFL