Provider Demographics
NPI:1467457416
Name:MAXIAN, TINA A (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:A
Last Name:MAXIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LEWIS RD
Mailing Address - Street 2:2ND FL
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:
Practice Address - Street 1:4433 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3556
Practice Address - Country:US
Practice Address - Phone:607-771-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231462174400000X, 207XX0801X, 207X00000X
ME017349207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02531579Medicaid
H84735Medicare UPIN
H84735Medicare UPIN