Healthcare Provider Details

I. General information

NPI: 1871589861
Provider Name (Legal Business Name): MAPLE MEDICAL SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MAPLE RD
WILLIAMSVILLE NY
14221-2918
US

IV. Provider business mailing address

41 MAPLE RD
WILLIAMSVILLE NY
14221-2918
US

V. Phone/Fax

Practice location:
  • Phone: 716-631-1045
  • Fax: 716-631-1365
Mailing address:
  • Phone: 716-631-1045
  • Fax: 716-631-1365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number187420
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number187420
License Number StateNY

VIII. Authorized Official

Name: THEODORE GERARD COSTICH
Title or Position: OWNER
Credential: M.D.
Phone: 716-631-1045