1811439433 NPI number — MAVERICK LABS LLC

Table of content: DR. WILLIAM JOSEPH PLAUS M.D. (NPI 1154326791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811439433 NPI number — MAVERICK LABS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAVERICK LABS LLC
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:
6
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:
1811439433
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 N CONGRESS AVE SUITE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-806-0990
Provider Business Mailing Address Fax Number:
561-423-2495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4601 N CONGRESS AVE SUITE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-806-0990
Provider Business Practice Location Address Fax Number:
561-423-2495
Provider Enumeration Date:
11/14/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HIRTH
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
561-504-8343

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  800028324 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100451700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".