Provider Demographics
NPI:1780712539
Name:MAXIDER CORPORATION
Entity type:Organization
Organization Name:MAXIDER CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:EDGARDO
Authorized Official - Last Name:DERBOGHOSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-488-6600
Mailing Address - Street 1:389 COMMERCIAL COURT
Mailing Address - Street 2:SUITE C
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292
Mailing Address - Country:US
Mailing Address - Phone:941-488-6600
Mailing Address - Fax:
Practice Address - Street 1:389 COMMERCIAL COURT
Practice Address - Street 2:SUITE C
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292
Practice Address - Country:US
Practice Address - Phone:941-488-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT13467225100000X, 2251G0304X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Not Answered2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7042130OtherAETNA NUMBER
FLCG9065OtherRR MEDICARE
FLY903SOtherBLUE CROSS NUMBER
FLK1357Medicare ID - Type UnspecifiedGROUP NUMBER