Provider Demographics
NPI:1891734919
Name:SMITH, MAXINE M (RD)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 N GANNETT RD
Mailing Address - Street 2:
Mailing Address - City:SAGAMORE HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44067-2921
Mailing Address - Country:US
Mailing Address - Phone:330-468-4062
Mailing Address - Fax:216-445-4356
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:800-223-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD2726133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000393115OtherANTHEM PIN
OH124252OtherKAISER PIN
OH7753436OtherAETNA GROUP PIN#
OH7429813OtherAETMA PIN #
OH7753436OtherANTARES PIN
OH7429813OtherAETMA PIN #