1336106459 NPI number — PHILLIP MAIDEN M.D.

Table of content: (NPI 1336106459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336106459 NPI number — PHILLIP MAIDEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILLIP MAIDEN M.D.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336106459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5384
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POLAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44514-0384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-758-4515
Provider Business Mailing Address Fax Number:
330-758-2862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1704 NORTH RD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44484-2958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-707-0610
Provider Business Practice Location Address Fax Number:
330-758-2862
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAIDEN
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
330-758-4515

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  35063252M , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2992047 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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