Provider Demographics
NPI:1457807414
Name:MAKSYMICZ, TANNER
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:MAKSYMICZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LINDEN LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-1076
Mailing Address - Country:US
Mailing Address - Phone:765-891-0503
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY CIR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-1367
Practice Address - Country:US
Practice Address - Phone:765-891-0503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960042592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer