Provider Demographics
NPI:1518966035
Name:GERKEN, MAXINE VICTORIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAXINE
Middle Name:VICTORIA
Last Name:GERKEN
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 1:4212 N 16TH ST
Mailing Address - Street 2:INTEGRATED SURGICAL SERVICE
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5319
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:602-200-5366
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:INTEGRATED SURGICAL SERVICE
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-200-5366
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64845208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G648450Medicaid
CAC47962Medicare UPIN
CA00G648450Medicare ID - Type UnspecifiedMEDICARE INDIV PROVIDER