Basic Information
| Provider Information | |||||||||
| NPI: | 1609025915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FADER | ||||||||
| FirstName: | MAGGIE | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EIDSON | ||||||||
| OtherFirstName: | MAGGIE | ||||||||
| OtherMiddleName: | C. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5955 PONCE DE LEON BLVD. | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331462423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056611515 | ||||||||
| FaxNumber: | 3056623723 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SW 62 AVE (#212, N.E. WING) | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056628360 | ||||||||
| FaxNumber: | 3056666387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2008 | ||||||||
| LastUpdateDate: | 01/02/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0207X | 237351 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2080P0207X | ME94494 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 274488100 | 05 | FL | MEDICAID |