Healthcare Provider Details

I. General information

NPI: 1417324955
Provider Name (Legal Business Name): MILLENNIUM INDEPENDENT PHYSICIAN NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 09/01/2015
Certification Date:
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

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

V. Phone/Fax

Practice location:
  • Phone: 855-674-7400
  • Fax: 855-674-7401
Mailing address:
  • Phone: 855-674-7400
  • Fax: 855-674-7401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: GEURT C PEET
Title or Position: CEO
Credential:
Phone: 855-674-7400