Provider Demographics
NPI:1659493849
Name:MILLENNIUM MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:MILLENNIUM MEDICAL GROUP, LLC
Other - Org Name:MILLENNIUM WELLNESS GROUP, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BEVERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:312-332-0844
Mailing Address - Street 1:111 N WABASH AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1903
Mailing Address - Country:US
Mailing Address - Phone:312-332-0844
Mailing Address - Fax:312-332-0847
Practice Address - Street 1:111 N WABASH AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1903
Practice Address - Country:US
Practice Address - Phone:312-332-0844
Practice Address - Fax:312-332-0847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009714111N00000X
IL070012487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty