Healthcare Provider Details

I. General information

NPI: 1215003082
Provider Name (Legal Business Name): MILLENIUM ANESTHESIOLOGISTS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2006
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1726 SHAWANO AVE
GREEN BAY WI
54303-3216
US

IV. Provider business mailing address

225 S EXECUTIVE DR
BROOKFIELD WI
53005-4266
US

V. Phone/Fax

Practice location:
  • Phone: 920-498-4200
  • Fax:
Mailing address:
  • Phone: 262-787-4026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES R HERON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 920-498-4200