Healthcare Provider Details

I. General information

NPI: 1316619182
Provider Name (Legal Business Name): MILLENNIUM PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 PALM BEACH BLVD STE 100
FORT MYERS FL
33905-3217
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 239-693-9191
  • Fax: 239-693-7369
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2612

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