Provider Demographics
NPI:1356479919
Name:MAXIS MEDICAL SERVICES
Entity Type:Organization
Organization Name:MAXIS MEDICAL SERVICES
Other - Org Name:MAXIS WOMEN'S HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUTRINOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-281-1001
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-0517
Mailing Address - Country:US
Mailing Address - Phone:570-281-1120
Mailing Address - Fax:
Practice Address - Street 1:141 SALEM AVE
Practice Address - Street 2:SUITE G2
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-2574
Practice Address - Country:US
Practice Address - Phone:570-281-1120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005206L207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA070104Medicare Oscar/Certification