1386725323 NPI number — DR. ROBERT JOSEPH MAIDEN

Table of content: (NPI 1619916418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386725323 NPI number — DR. ROBERT JOSEPH MAIDEN

Organization/Personal Information

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

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:
1386725323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 MARTIN ST, SUITE 3
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
WELLSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-593-9815
Provider Business Mailing Address Fax Number:
585-596-4048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 MARTIN ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
WELLSVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-593-1859
Provider Business Practice Location Address Fax Number:
585-593-2465
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  006688-2 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 006688 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00781659 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000500140001 . This is a "BLUE SHIELD WESTERN NY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 260011314 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6107819 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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