Basic Information
Provider Information | |||||||||
NPI: | 1730142704 | ||||||||
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 RD | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | MD | ||||||||
PostalCode: | 210463236 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109101500 | ||||||||
FaxNumber: | 4109101600 | ||||||||
Practice Location | |||||||||
Address1: | 1160 DAIRY ASHFORD ST | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770793022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2815971553 | ||||||||
FaxNumber: | 2815971529 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2006 | ||||||||
LastUpdateDate: | 09/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WALSH | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 4109101581 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 251E00000X | 005076 | TX | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | K04593635 | 05 | TX |   | MEDICAID | 001002325 | 05 | TX |   | MEDICAID | 1129074-01 | 05 | TX |   | MEDICAID |