1922023894 NPI number — JODI P MAXFIELD MD

Table of content: JODI P MAXFIELD MD (NPI 1922023894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922023894 NPI number — JODI P MAXFIELD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAXFIELD
Provider First Name:
JODI
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POWLUS
Provider Other First Name:
JODI
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922023894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
765 LIBERTY STREET
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
MEADVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16335-2568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-333-5888
Provider Business Mailing Address Fax Number:
814-333-5026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
765 LIBERTY STREET
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16335-2568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-333-5888
Provider Business Practice Location Address Fax Number:
814-333-5026
Provider Enumeration Date:
07/13/2006

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: 207V00000X , with the licence number:  MD417934 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0019009800001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 310927 . This is a "UPMC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1379522 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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