Provider Demographics
NPI:1700914686
Name:MILLENNIUM MEDICAL GROUP
Entity Type:Organization
Organization Name:MILLENNIUM MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:LULKIN
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:734-462-2700
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:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION48230Medicare ID - Type Unspecified