Provider Demographics
NPI:1518009414
Name:MAXIS MEDICAL SERVICES
Entity Type:Organization
Organization Name:MAXIS MEDICAL SERVICES
Other - Org Name:PEDIATRIC CARE
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:570-281-1287
Mailing Address - Fax:570-281-1256
Practice Address - Street 1:42 N SCOTT ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-1888
Practice Address - Country:US
Practice Address - Phone:570-282-6660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA887913OtherBLUE SHIELD