Healthcare Provider Details

I. General information

NPI: 1366645376
Provider Name (Legal Business Name): MILLENNIUM MEDICAL MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7955 SPYGLASS HILL RD STE A
MELBOURNE FL
32940-8249
US

IV. Provider business mailing address

7955 SPYGLASS HILL RD STE A
MELBOURNE FL
32940-8249
US

V. Phone/Fax

Practice location:
  • Phone: 321-255-6670
  • Fax: 321-242-2545
Mailing address:
  • Phone: 321-255-6670
  • Fax: 321-242-2545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME84856
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME95180
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberME95180
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME93866
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME111580
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS12589
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME93866
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME111580
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS12589
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME93866
License Number StateFL
# 11
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME93866
License Number StateFL
# 12
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME111580
License Number StateFL
# 13
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License NumberIAC ACCREDITED 7422
License Number StateFL
# 14
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9105911
License Number StateFL
# 15
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberME82061
License Number StateFL

VIII. Authorized Official

Name: SUN MEE DEUKMEDJIAN
Title or Position: FINANCIAL OFFICER
Credential:
Phone: 321-775-1290