Provider Demographics
NPI:1982270526
Name:MILLENIAL MEDICAL GROUP
Entity Type:Organization
Organization Name:MILLENIAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MHA
Authorized Official - Phone:787-477-3507
Mailing Address - Street 1:199 CALLE GRAN BRETANA
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-3517
Mailing Address - Country:US
Mailing Address - Phone:787-477-3507
Mailing Address - Fax:
Practice Address - Street 1:199 CALLE GRAN BRETANA
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-3517
Practice Address - Country:US
Practice Address - Phone:787-477-3507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty