=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750348926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAXUM HEALTH SERVICES CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2006
-----------------------------------------------------
Last Update Date | 08/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11617 N CENTRAL EXPY STE 132
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75243-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-369-3795
-----------------------------------------------------
Fax | 214-692-7953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 848074
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75284-8074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-282-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER; TREASURER
-----------------------------------------------------
Name | JAMES F. STANLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-282-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 293D00000X
-----------------------------------------------------
Taxonomy Name | Physiological Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------