Healthcare Provider Details

I. General information

NPI: 1821661919
Provider Name (Legal Business Name): MILLENNIUM PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 ARCOS AVE STE 105
ESTERO FL
33928-9460
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 239-226-2727
  • Fax: 239-939-9876
Mailing address:
  • Phone: 877-856-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY HALTIGAN
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 877-856-3774