MEDICARE: MILENIA IPA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305R00000X	Preferred Provider Organization		NY

General Provider Information

NPI Number	:	1316499742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILENIA IPA LLC

Provider Business Mailing Address
First Line	:	945 BROADWAY
Second Line	:
City	:	WOODMERE
State	:	NY
Zip	:	11598-1733
Country	:	US
Telephone Number	:	516-537-4913
Fax Number	:	516-537-4910

Provider Business Practice Location Address
First Line	:	945 BROADWAY
Second Line	:
City	:	WOODMERE
State	:	NY
Zip	:	11598-1733
Country	:	US
Telephone Number	:	516-537-4913
Fax Number	:	516-537-4910

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	BENT PHILIPSON
Credential	:
Telephone Number	:	516-537-4913

Provider Enumeration Date	:	11/02/2016
Last Update Date	:	11/02/2016

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