MEDICARE: ROBERT A MAINES RN

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	163WA2000X	Administrator Registered Nurse	28168982A	IN
2	163WC0200X	Critical Care Medicine Registered Nurse	28168982A	IN
3	163WE0003X	Emergency Registered Nurse	28168982A	IN
4	163WX1100X	Ophthalmic Registered Nurse	28168982A	IN

General Provider Information

NPI Number	:	1720387921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT A MAINES RN

Provider Business Mailing Address
First Line	:	4252 E 100 S APT 3
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46902-9129
Country	:	US
Telephone Number	:	765-428-8888
Fax Number	:	765-428-8889

Provider Business Practice Location Address
First Line	:	1013 N 13TH ST
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47904-2011
Country	:	US
Telephone Number	:	765-428-8888
Fax Number	:	765-428-8889

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2011
Last Update Date	:	03/28/2011

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