Provider Demographics
NPI:1154477594
Name:MAISEN MEDICAL PRACTICE, INC
Entity Type:Organization
Organization Name:MAISEN MEDICAL PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUDMILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAISEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-234-2598
Mailing Address - Street 1:1453 W ISLAND CLUB SQ
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-5519
Mailing Address - Country:US
Mailing Address - Phone:772-234-2598
Mailing Address - Fax:772-365-0333
Practice Address - Street 1:1453 W ISLAND CLUB SQ
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-5519
Practice Address - Country:US
Practice Address - Phone:772-234-2598
Practice Address - Fax:772-365-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7887Medicare ID - Type Unspecified