Basic Information
| Provider Information | |||||||||
| NPI: | 1639132673 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAXIM HEALTHCARE SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7227 LEE DEFOREST DRIVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210463405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109101500 | ||||||||
| FaxNumber: | 4109101600 | ||||||||
| Practice Location | |||||||||
| Address1: | 3050 N ROADRUNNER PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880110820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055228811 | ||||||||
| FaxNumber: | 5055228822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOWALCZYK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4109101730 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | IT3204 | NM | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 24556831 | 05 | NM | MEDICAID |