Provider Demographics
NPI:1659049963
Name:MILLENIUM MEDICAL GROUP CORP
Entity Type:Organization
Organization Name:MILLENIUM MEDICAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAMARYS
Authorized Official - Middle Name:
Authorized Official - Last Name:SUAREZ QUIRIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-332-4330
Mailing Address - Street 1:2720 SW 97TH AVE STE C105
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-2677
Mailing Address - Country:US
Mailing Address - Phone:786-332-4330
Mailing Address - Fax:305-381-0135
Practice Address - Street 1:2720 SW 97TH AVE STE C105
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-2677
Practice Address - Country:US
Practice Address - Phone:786-332-4330
Practice Address - Fax:305-381-0135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107892800Medicaid