Basic Information
| Provider Information | |||||||||
| NPI: | 1164533543 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAXIM OF NEW YORK, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAXIM HEALTHCARE SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7227 LEE DEFOREST DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210463236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109101500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 777 WESTCHESTER AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106043520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149970420 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | SIPES | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4109101500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 1121L001 | NY | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 02319175-003 | 05 | NY | MEDICAID | 02324385 | 05 | NY | MEDICAID |