Basic Information
| Provider Information | |||||||||
| NPI: | 1194168005 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAKSIMOWSKI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4646 JOHN R ST RM B2340 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
| FaxNumber: | 3139661195 | ||||||||
| Practice Location | |||||||||
| Address1: | 4646 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
| FaxNumber: | 3139661195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2013 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0015X | 4301114125 | MI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine | 2084P0800X | 4301114125 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.