Provider Demographics
NPI:1962791467
Name:SMITH, MAXIMILIAN JAMES (MD)
Entity type:Individual
Prefix:
First Name:MAXIMILIAN
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MALL ROAD
Mailing Address - Street 2:LAHEY HOSPITAL & MEDICAL CENTER
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8170
Mailing Address - Fax:781-744-5232
Practice Address - Street 1:41 MALL ROAD
Practice Address - Street 2:LAHEY HOSPITAL & MEDICAL CENTER
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8170
Practice Address - Fax:781-744-5232
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO578982085R0202X
MA2660932085R0202X, 2085D0003X, 2085N0700X, 2085R0202X, 2085N0700X
TXR18812085R0202X
KS04-396762085R0202X
NE298492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENA1214108OtherMEDICARE PIN
KS111257095OtherMEDICARE PIN
CO559221YQN9OtherMEDICARE PIN
CO559221YQPGOtherMEDICARE PIN
CO559221ZLJ3OtherMEDICARE PIN
NENA1215109OtherMEDICARE PIN
CO559221YQ33OtherMEDICARE PIN
KSKA3249086OtherMEDICARE PIN
CO16317513Medicaid
HIH109845OtherMEDICARE PIN
HIH109846OtherMEDICARE PIN
HIH109847OtherMEDICARE PIN
NENA2517086OtherMEDICARE PIN
CO559221YQ33OtherMEDICARE PIN
KSKA3249086Medicare PIN
HIH109845OtherMEDICARE PIN
NENA1214108Medicare PIN
HIH109847OtherMEDICARE PIN
KSKA3249086OtherMEDICARE PIN
CO559221YQ33Medicare PIN
NENA1215109OtherMEDICARE PIN
KS111257095Medicare PIN
CO559221YQN9OtherMEDICARE PIN
CO16317513Medicaid
NENA2517086Medicare PIN