1467879387 NPI number — MAXIM OF NEW YORK, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467879387 NPI number — MAXIM OF NEW YORK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAXIM OF NEW YORK, 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:
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:
1467879387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7227 LEE DEFOREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21046-3236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-910-1500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 WOLF RD
Provider Second Line Business Practice Location Address:
SUITE 100A
Provider Business Practice Location Address City Name:
COLONIE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12205-6007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-437-0152
Provider Business Practice Location Address Fax Number:
855-415-4970
Provider Enumeration Date:
03/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SIPES
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL VP OF FINANCE
Authorized Official Telephone Number:
410-910-1500

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1121L005 , 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)





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