Provider Demographics
NPI:1629103197
Name:MILLENNIUM MEDICAL GROUP WEST P.C.
Entity Type:Organization
Organization Name:MILLENNIUM MEDICAL GROUP WEST P.C.
Other - Org Name:MILLENNIUM WEST PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL
Authorized Official - Prefix:
Authorized Official - First Name:LUANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-462-2700
Mailing Address - Street 1:38807 ANN ARBOR RD STE 7
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3896
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38807 ANN ARBOR RD STE 7
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-3896
Practice Address - Country:US
Practice Address - Phone:734-462-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30783OtherBLUE CROSS BLUE SHIELD
MI236739Medicare PIN