Provider Demographics
NPI:1396940300
Name:MAXIS MEDICAL SERVICES
Entity type:Organization
Organization Name:MAXIS MEDICAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:THERESA
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:570-281-1315
Mailing Address - Fax:570-281-1256
Practice Address - Street 1:MAIN STREET
Practice Address - Street 2:
Practice Address - City:CLIFFORD
Practice Address - State:PA
Practice Address - Zip Code:18413-0120
Practice Address - Country:US
Practice Address - Phone:570-222-5200
Practice Address - Fax:570-222-5201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008778L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA070104Medicare Oscar/Certification