Provider Demographics
NPI:1639342330
Name:MAXINE M. ANDERSON, M.D., INC.
Entity Type:Organization
Organization Name:MAXINE M. ANDERSON, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-213-4290
Mailing Address - Street 1:3628 E IMPERIAL HWY
Mailing Address - Street 2:SUITE 401
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2643
Mailing Address - Country:US
Mailing Address - Phone:424-213-4290
Mailing Address - Fax:424-213-4295
Practice Address - Street 1:3628 E IMPERIAL HWY
Practice Address - Street 2:SUITE 401
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2643
Practice Address - Country:US
Practice Address - Phone:424-213-4290
Practice Address - Fax:424-213-4295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA687832086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA68783Medicare PIN