Basic Information
| Provider Information | |||||||||
| NPI: | 1386675148 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAKSYMIW | ||||||||
| FirstName: | STEFAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 EDWARDS MILL RD | ||||||||
| Address2: | 200 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276125243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197814060 | ||||||||
| FaxNumber: | 9197815246 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 ASHVILLE AVE | ||||||||
| Address2: | SUITE 20 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275186130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198635924 | ||||||||
| FaxNumber: | 9198635923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9789 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 079PP | 01 | NC | BCBSNC | OTHER |