Provider Demographics
NPI:1871589861
Name:MAPLE MEDICAL SERVICES, P.C.
Entity type:Organization
Organization Name:MAPLE MEDICAL SERVICES, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:COSTICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-631-1045
Mailing Address - Street 1:41 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2918
Mailing Address - Country:US
Mailing Address - Phone:716-631-1045
Mailing Address - Fax:716-631-1365
Practice Address - Street 1:41 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2918
Practice Address - Country:US
Practice Address - Phone:716-631-1045
Practice Address - Fax:716-631-1365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187420207V00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Not Answered207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01406720Medicaid
NY00020006503OtherUNIVERA ID #
NY0709667OtherIHA PROVIDER #
NYF04493Medicare UPIN
NY00020006503OtherUNIVERA ID #
NYAA0164Medicare ID - Type UnspecifiedGROUP MEDICARE ID