MEDICARE: MAXX MEDICAL INC

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	305S00000X	Point of Service

General Provider Information

NPI Number	:	1457005464
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAXX MEDICAL INC

Provider Business Mailing Address
First Line	:	10554 SUCCESS LN STE A
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-3657
Country	:	US
Telephone Number	:	937-438-9500
Fax Number	:	937-886-5694

Provider Business Practice Location Address
First Line	:	10554 SUCCESS LN STE A
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-3657
Country	:	US
Telephone Number	:	937-438-9500
Fax Number	:	937-886-5694

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	SHEILA PETREQUIN
Credential	:
Telephone Number	:	937-438-9500

Provider Enumeration Date	:	02/08/2022
Last Update Date	:	02/08/2022

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Directions to “MAXX MEDICAL INC ” Practice Location

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