Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | PT028012 | PA |
Y | 213ES0000X | Sports Medicine | PT028012 | PA |
NPI | 1457906802 |
---|---|
Provider Name | Stephen Maze |
First Address | Bala Cynwyd, PA 19004-1108 |
Second Address | Bala Cynwyd, PA 19004-1108 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2019 |
Last Update Date | 02/08/2019 |