Healthcare Provider Details

I. General information

NPI: 1962791467
Provider Name (Legal Business Name): MAXIMILIAN JAMES SMITH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MALL ROAD LAHEY HOSPITAL & MEDICAL CENTER
BURLINGTON MA
01805-0001
US

IV. Provider business mailing address

41 MALL ROAD LAHEY HOSPITAL & MEDICAL CENTER
BURLINGTON MA
01805-0001
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-8170
  • Fax: 781-744-5232
Mailing address:
  • Phone: 781-744-8170
  • Fax: 781-744-5232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number57898
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number266093
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number266093
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number266093
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: