Healthcare Provider Details

I. General information

NPI: 1659493849
Provider Name (Legal Business Name): MILLENNIUM MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N WABASH AVE SUITE 600
CHICAGO IL
60602-1903
US

IV. Provider business mailing address

111 N WABASH AVE SUITE 600
CHICAGO IL
60602-1903
US

V. Phone/Fax

Practice location:
  • Phone: 312-332-0844
  • Fax: 312-332-0847
Mailing address:
  • Phone: 312-332-0844
  • Fax: 312-332-0847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038009714
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070012487
License Number StateIL

VIII. Authorized Official

Name: DR. JENNIFER LYNN BEVERLIN
Title or Position: PARTNER
Credential: D.C.
Phone: 312-332-0844