MEDICARE: DR. MAXIME JEAN-MARIE COLES M.D.

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	207X00000X	Orthopaedic Surgery Physician	04-31291	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	269-384-4	OTHER		ECFMG
2	2003025339	OTHER	MO	MEDICAL LICENSE
3	04-31291	OTHER	KS	MEDICAL LICENSE
4	26249	OTHER	CT	MEDICAL LICENSE

General Provider Information

NPI Number	:	1578560207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAXIME JEAN-MARIE COLES M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1176
Second Line	:
City	:	COFFEYVILLE
State	:	KS
Zip	:	67337-0919
Country	:	US
Telephone Number	:	620-251-3838
Fax Number	:	620-251-0736

Provider Business Practice Location Address
First Line	:	1411 W 4TH ST
Second Line	:	BUILDING C
City	:	COFFEYVILLE
State	:	KS
Zip	:	67337-3300
Country	:	US
Telephone Number	:	620-251-3838
Fax Number	:	620-251-0736

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/08/2007

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