Basic Information
Provider Information | |||||||||
NPI: | 1619084050 | ||||||||
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: | 1300 CITIZENS BLVD STE 150 | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 347483966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3523607291 | ||||||||
FaxNumber: | 8773068306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOWALCZYK | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 4109101500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 299991802 | FL | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 651014196 | 05 | FL |   | MEDICAID | 001130000 | 05 | FL |   | MEDICAID | 651014100 | 05 | FL |   | MEDICAID | 687097000 | 05 | FL |   | MEDICAID |