Provider Demographics
NPI:1447247556
Name:MAYNARD, FREDERICK M JR (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:M
Last Name:MAYNARD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:580 W COLLEGE AVE
Mailing Address - Street 2:SKYWALK
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2705
Mailing Address - Country:US
Mailing Address - Phone:906-225-3914
Mailing Address - Fax:906-225-4583
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:SKYWALK
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-225-3914
Practice Address - Fax:906-225-4583
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI028676208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI250E26047OtherBLUE CROSS BLUE SHIELD MI
MI4083530Medicaid
MIA36041Medicare UPIN
MI250E26047OtherBLUE CROSS BLUE SHIELD MI
MI4083530Medicaid