Provider Demographics
NPI:1629784376
Name:MAYBACH NEUROSURGERY CLINIC LLC
Entity Type:Organization
Organization Name:MAYBACH NEUROSURGERY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-457-7117
Mailing Address - Street 1:1545 HAND AVE STE A1
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-1140
Mailing Address - Country:US
Mailing Address - Phone:386-457-7117
Mailing Address - Fax:
Practice Address - Street 1:1545 HAND AVE STE A1
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-1140
Practice Address - Country:US
Practice Address - Phone:386-457-7117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty