MEDICARE: GREGORY MADDOX

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	2831811	NY

General Provider Information

NPI Number	:	1285952259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY MADDOX

Provider Business Mailing Address
First Line	:	400 STOCKHOLM ST APT 2F
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11237-4008
Country	:	US
Telephone Number	:	347-967-6522
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 STOCKHOLM ST APT 2F
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11237-4008
Country	:	US
Telephone Number	:	347-967-6522
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2010
Last Update Date	:	05/14/2010

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