Healthcare Provider Details

I. General information

NPI: 1003851460
Provider Name (Legal Business Name): MICHAEL MAITLAND M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 11/27/2023
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8081 INNOVATION PARK DR
FAIRFAX VA
22031-4867
US

IV. Provider business mailing address

540 N STATE ST APT 3111
CHICAGO IL
60610-7231
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-4724
  • Fax: 571-472-1601
Mailing address:
  • Phone: 312-595-1819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number036-109601
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License Number036-109601
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number0101261271
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: