Healthcare Provider Details

I. General information

NPI: 1720387921
Provider Name (Legal Business Name): ROBERT A MAINES RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 03/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 N 13TH ST
LAFAYETTE IN
47904-2011
US

IV. Provider business mailing address

4252 E 100 S APT 3
KOKOMO IN
46902-9129
US

V. Phone/Fax

Practice location:
  • Phone: 765-428-8888
  • Fax: 765-428-8889
Mailing address:
  • Phone: 765-428-8888
  • Fax: 765-428-8889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number28168982A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number28168982A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number28168982A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code163WX1100X
TaxonomyOphthalmic Registered Nurse
License Number28168982A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: