Basic Information
| Provider Information | |||||||||
| NPI: | 1720245129 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAXIM HEALTHCARE SERVICES, INC. | ||||||||
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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: | 445 NW PRIMA VISTA BLVD | ||||||||
| Address2: | UNIT 107 | ||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349838731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617342371 | ||||||||
| FaxNumber: | 5617338599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 01/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4109101500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 299993344 | FL | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 000534100 | 05 | FL | MEDICAID |