Provider Demographics
NPI:1558500744
Name:MILLENNIUM MEDICAL GROUP SOUTH PC
Entity Type:Organization
Organization Name:MILLENNIUM MEDICAL GROUP SOUTH PC
Other - Org Name:MILLENNIUM SOUTH DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SLAIM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-295-3388
Mailing Address - Street 1:8850 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-2316
Mailing Address - Country:US
Mailing Address - Phone:313-299-2360
Mailing Address - Fax:313-299-2362
Practice Address - Street 1:8850 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-2316
Practice Address - Country:US
Practice Address - Phone:313-299-2360
Practice Address - Fax:313-299-2362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty