Provider Demographics
NPI:1518299890
Name:MILLENNIUM MEDICAL ALPHARETTA
Entity type:Organization
Organization Name:MILLENNIUM MEDICAL ALPHARETTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIENE
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-395-7233
Mailing Address - Street 1:12755 CENTURY DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-8377
Mailing Address - Country:US
Mailing Address - Phone:678-395-7233
Mailing Address - Fax:
Practice Address - Street 1:12755 CENTURY DR UNIT A
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-8377
Practice Address - Country:US
Practice Address - Phone:678-395-7233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-11
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268693700Medicaid
FLI04565Medicare UPIN
FL268693700Medicaid