Provider Demographics
NPI:1629585906
Name:MILLENIUM MEDICAL GROUP CORP.
Entity Type:Organization
Organization Name:MILLENIUM MEDICAL GROUP CORP.
Other - Org Name:MILLENIUM MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DAMARYS
Authorized Official - Middle Name:
Authorized Official - Last Name:SUAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-613-0798
Mailing Address - Street 1:2740 SW 97TH AVE STE A-111
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2681
Mailing Address - Country:US
Mailing Address - Phone:786-332-4330
Mailing Address - Fax:786-332-4109
Practice Address - Street 1:2740 SW 97TH AVE
Practice Address - Street 2:SUITE NUMBER A-111
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3316
Practice Address - Country:US
Practice Address - Phone:786-332-4330
Practice Address - Fax:786-332-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9227984207QA0505X
FLMA64254225700000X
251S00000X, 261QM0801X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health