Provider Demographics
NPI:1063418168
Name:MAIDEN, PHILLIP G (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:G
Last Name:MAIDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:PO BOX 5384
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-0384
Mailing Address - Country:US
Mailing Address - Phone:330-758-4515
Mailing Address - Fax:330-758-5121
Practice Address - Street 1:1704 NORTH RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2958
Practice Address - Country:US
Practice Address - Phone:330-758-4515
Practice Address - Fax:330-758-5121
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35063252M2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4014891Medicare PIN