Provider Demographics
NPI:1386725695
Name:MILLENNIUM MEDICAL GROUP PC
Entity type:Organization
Organization Name:MILLENNIUM MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FULGENCIO-DELMONTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-404-9157
Mailing Address - Street 1:93-20A ROOSEVELT AVE.
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7904
Mailing Address - Country:US
Mailing Address - Phone:718-404-9157
Mailing Address - Fax:718-334-6701
Practice Address - Street 1:93-20A ROOSEVELT AVE.
Practice Address - Street 2:2ND FLOOR
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7904
Practice Address - Country:US
Practice Address - Phone:718-404-9157
Practice Address - Fax:718-424-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203635207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01664373Medicaid
NY01664373Medicaid