Healthcare Provider Details

I. General information

NPI: 1275971764
Provider Name (Legal Business Name): MILLENNIUM PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 DANIELS PKWY STE 201
FORT MYERS FL
33912-4773
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 855-674-7401
  • Fax: 941-258-3292
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
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

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