Basic Information
| Provider Information | |||||||||
| NPI: | 1639280100 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAXIM OF NEW YORK, LLC | ||||||||
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| OtherOrganizationName: | MAXIM HEALTHCARE SERVICES, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7227 LEE DEFOREST DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210463236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109101500 | ||||||||
| FaxNumber: | 4109101600 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 W GENESEE ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154760600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | KOWALCZYK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4109101500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAXIM HEALTHCARE SERVICES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 1121L002 | NY | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0232438504 | 05 | NY | MEDICAID | 02621396-004 | 05 | NY | MEDICAID |