Basic Information
| Provider Information | |||||||||
| NPI: | 1912960832 | ||||||||
| 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: | 933 N MAYFAIR RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144759330 | ||||||||
| FaxNumber: | 4144759350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | WALSH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4109101581 | ||||||||
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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 | 1029 | WI | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 4153-7700 | 05 | WI | MEDICAID |