Basic Information
| Provider Information | |||||||||
| NPI: | 1962791467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MAXIMILIAN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41 MALL ROAD | ||||||||
| Address2: | LAHEY HOSPITAL & MEDICAL CENTER | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448170 | ||||||||
| FaxNumber: | 7817445232 | ||||||||
| Practice Location | |||||||||
| Address1: | 41 MALL ROAD | ||||||||
| Address2: | LAHEY HOSPITAL & MEDICAL CENTER | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448170 | ||||||||
| FaxNumber: | 7817445232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2011 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 57898 | CO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 266093 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085D0003X | 266093 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2085N0700X | 266093 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | NA1214108 | 01 | NE | MEDICARE PIN | OTHER | 111257095 | 01 | KS | MEDICARE PIN | OTHER | 559221YQN9 | 01 | CO | MEDICARE PIN | OTHER | 559221YQPG | 01 | CO | MEDICARE PIN | OTHER | 559221ZLJ3 | 01 | CO | MEDICARE PIN | OTHER | NA1215109 | 01 | NE | MEDICARE PIN | OTHER | 559221YQ33 | 01 | CO | MEDICARE PIN | OTHER | KA3249086 | 01 | KS | MEDICARE PIN | OTHER | 16317513 | 05 | CO | MEDICAID | H109845 | 01 | HI | MEDICARE PIN | OTHER | H109846 | 01 | HI | MEDICARE PIN | OTHER | H109847 | 01 | HI | MEDICARE PIN | OTHER | NA2517086 | 01 | NE | MEDICARE PIN | OTHER |