MEDICARE: MAXILLOFACIAL SURGERY INNOVATIVE SERVICES

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	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962929240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAXILLOFACIAL SURGERY INNOVATIVE SERVICES

Provider Business Mailing Address
First Line	:	1284 SOM CENTER RD STE 219
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-2048
Country	:	US
Telephone Number	:	888-774-7773
Fax Number	:	888-774-7970

Provider Business Practice Location Address
First Line	:	1284 SOM CENTER RD STE 219
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-2048
Country	:	US
Telephone Number	:	888-774-7773
Fax Number	:	888-774-7970

Authorized Official
Title or Position	:	CREDENTIALING DIRECTOR
Name	:	MICHELLE ANN HANCOCK
Credential	:	MS/P, MBA/HCM
Telephone Number	:	515-321-6451

Provider Enumeration Date	:	08/28/2017
Last Update Date	:	07/21/2022

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