Healthcare Provider Details

I. General information

NPI: 1932546801
Provider Name (Legal Business Name): MAKSIM KOROTUN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

410 LAKEVILLE RD STE 107
NEW HYDE PARK NY
11042-1102
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-2000
  • Fax:
Mailing address:
  • Phone: 516-465-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOT015307
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number284738-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number284738-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: