Provider Demographics
NPI:1912869074
Name:MACON, MAXIMILLION
Entity type:Individual
Prefix:
First Name:MAXIMILLION
Middle Name:
Last Name:MACON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-4257
Mailing Address - Country:US
Mailing Address - Phone:773-799-4899
Mailing Address - Fax:
Practice Address - Street 1:10001 GRAND AVE STE 1
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131-2564
Practice Address - Country:US
Practice Address - Phone:847-451-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-26
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist