1659410504 NPI number — MAXIS MEDICAL SERVICES

Table of content: (NPI 1659410504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659410504 NPI number — MAXIS MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAXIS MEDICAL SERVICES
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:
1659410504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 517
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18407-0517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-281-1287
Provider Business Mailing Address Fax Number:
570-281-1256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
263 CARBONDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYMART
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18472-9113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-488-5544
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAUTRINOT
Authorized Official First Name:
MARY THERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
570-281-1315

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1467916 . This is a "PENNA BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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