Healthcare Provider Details

I. General information

NPI: 1629417886
Provider Name (Legal Business Name): MAXIMO JAMES MARIN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE MC 3083, DEPARTMENT OF PATHOLOGY
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

1600 SW ARCHER RD BOX 100275
GAINESVILLE FL
32610
US

V. Phone/Fax

Practice location:
  • Phone: 773-834-7708
  • Fax:
Mailing address:
  • Phone: 352-273-7839
  • Fax: 352-273-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036142195
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberME151533
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: