Provider Demographics
NPI:1740460211
Name:MILLENNIUM MEDICAL P C
Entity type:Organization
Organization Name:MILLENNIUM MEDICAL P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SOLOMON
Authorized Official - Middle Name:
Authorized Official - Last Name:NOGUERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-931-3667
Mailing Address - Street 1:1153 E GANNON DR
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-2611
Mailing Address - Country:US
Mailing Address - Phone:636-931-3667
Mailing Address - Fax:
Practice Address - Street 1:1153 E GANNON DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2611
Practice Address - Country:US
Practice Address - Phone:636-931-3667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8H32207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000013777Medicare PIN
MOG14332Medicare UPIN