Healthcare Provider Details

I. General information

NPI: 1184042533
Provider Name (Legal Business Name): BRIAN MIKULAN MAXFIELD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

1928 45TH ST
MUNSTER IN
46321-3917
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9169
  • Fax:
Mailing address:
  • Phone: 219-476-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MB10550200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number02006029A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036141740
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: