Provider Demographics
NPI:1417324955
Name:MILLENNIUM INDEPENDENT PHYSICIAN NETWORK
Entity Type:Organization
Organization Name:MILLENNIUM INDEPENDENT PHYSICIAN NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEURT
Authorized Official - Middle Name:C
Authorized Official - Last Name:PEET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-674-7400
Mailing Address - Street 1:6321 DANIELS PKWY
Mailing Address - Street 2:STE 201
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4773
Mailing Address - Country:US
Mailing Address - Phone:855-674-7400
Mailing Address - Fax:855-674-7401
Practice Address - Street 1:6321 DANIELS PKWY
Practice Address - Street 2:STE 201
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4773
Practice Address - Country:US
Practice Address - Phone:855-674-7400
Practice Address - Fax:855-674-7401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLENNIUM HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
302R00000XOtherTAXONOMY CODE