Provider Demographics
NPI:1033398144
Name:PHILIP A MAYNARD
Entity Type:Organization
Organization Name:PHILIP A MAYNARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:402-462-2788
Mailing Address - Street 1:416 N MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5254
Mailing Address - Country:US
Mailing Address - Phone:402-462-2788
Mailing Address - Fax:402-462-4783
Practice Address - Street 1:416 N MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5254
Practice Address - Country:US
Practice Address - Phone:402-462-2788
Practice Address - Fax:402-462-4783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE159332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1197710001Medicare NSC