1730103730 NPI number — KENNETH MITCHUM MAYNARD D.O.

Table of content: KENNETH MITCHUM MAYNARD D.O. (NPI 1730103730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730103730 NPI number — KENNETH MITCHUM MAYNARD D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYNARD
Provider First Name:
KENNETH
Provider Middle Name:
MITCHUM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1730103730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 SOUTHFIELD DR
Provider Second Line Business Mailing Address:
SUITE 1370
Provider Business Mailing Address City Name:
PLAINFIELD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46168-4498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-837-5571
Provider Business Mailing Address Fax Number:
317-837-5580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1045 WYATT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIZTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46149-9583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-994-6600
Provider Business Practice Location Address Fax Number:
317-994-6605
Provider Enumeration Date:
07/26/2006

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: 207Q00000X , with the licence number:  02000836A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200932990 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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