MEDICARE: MAISEN MEDICAL PRACTICE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1154477594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAISEN MEDICAL PRACTICE, INC

Provider Business Mailing Address
First Line	:	1453 W ISLAND CLUB SQ
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32963-5519
Country	:	US
Telephone Number	:	772-234-2598
Fax Number	:	772-365-0333

Provider Business Practice Location Address
First Line	:	1453 W ISLAND CLUB SQ
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32963-5519
Country	:	US
Telephone Number	:	772-234-2598
Fax Number	:	772-365-0333

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LUDMILLA MAISEN
Credential	:	M.D.
Telephone Number	:	772-234-2598

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	08/22/2020

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