MEDICARE: MILLENNIUM PHYSICIAN GROUP 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1417629106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLENNIUM PHYSICIAN GROUP LLC

Provider Business Mailing Address
First Line	:	2675 WINKLER AVE FL 2
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-9342
Country	:	US
Telephone Number	:	877-856-3774
Fax Number	:	239-599-2612

Provider Business Practice Location Address
First Line	:	1351 13TH AVE S STE 110
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3237
Country	:	US
Telephone Number	:	904-249-9995
Fax Number	:	904-249-9449

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE CYCLE
Name	:	MARY HALTIGAN
Credential	:
Telephone Number	:	877-856-3774

Provider Enumeration Date	:	09/30/2021
Last Update Date	:	01/18/2023

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