Healthcare Provider Details

I. General information

NPI: 1073603999
Provider Name (Legal Business Name): MAUMEE PEDIATRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W SOPHIA ST
MAUMEE OH
43537-1848
US

IV. Provider business mailing address

520 W SOPHIA ST
MAUMEE OH
43537-1848
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-1880
  • Fax: 419-893-1242
Mailing address:
  • Phone: 419-893-1880
  • Fax: 419-893-1242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35972439-O
License Number StateOH

VIII. Authorized Official

Name: MRS. SANDRA M. SWANDER
Title or Position: OFFICE MANAGER
Credential:
Phone: 419-893-1880