=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164569604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLENIUM MEDICAL EMERGENCY GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HOSPITAL SAN JUAN BAUTISTA URB TURABO GARDENS CARR 172
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-653-0550
-----------------------------------------------------
Fax | 787-745-0708
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PMB 171 BOX 4956
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00726-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-745-0708
-----------------------------------------------------
Fax | 787-745-0708
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GUILLERMO F CAMPOS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-745-0708
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0002X
-----------------------------------------------------
Taxonomy Name | Emergency Care Clinic/Center
-----------------------------------------------------
License Number | 12308
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------