Basic Information
Provider Information | |||||||||
NPI: | 1437325586 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAXIM HEALTHCARE SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7227 LEE DEFOREST DR | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | MD | ||||||||
PostalCode: | 210463236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109101500 | ||||||||
FaxNumber: | 4109101600 | ||||||||
Practice Location | |||||||||
Address1: | 11330 OLIVE BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631417149 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3145693935 | ||||||||
FaxNumber: | 3145693305 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/07/2008 | ||||||||
LastUpdateDate: | 05/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALSH | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 4109101500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X |   |   | Y |   | Respite Care Facility | Respite Care |   |
ID Information
ID | Type | State | Issuer | Description | 288103609 | 05 | MO |   | MEDICAID |