Provider Demographics
NPI:1962929240
Name:MAXILLOFACIAL SURGERY INNOVATIVE SERVICES
Entity type:Organization
Organization Name:MAXILLOFACIAL SURGERY INNOVATIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MS/P, MBA/HCM
Authorized Official - Phone:515-321-6451
Mailing Address - Street 1:1284 SOM CENTER RD STE 219
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2048
Mailing Address - Country:US
Mailing Address - Phone:888-774-7773
Mailing Address - Fax:888-774-7970
Practice Address - Street 1:1284 SOM CENTER RD STE 219
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2048
Practice Address - Country:US
Practice Address - Phone:888-774-7773
Practice Address - Fax:888-774-7970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2855503Medicaid