Provider Demographics
NPI:1023758927
Name:GILMORE, MAXWELL C
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:C
Last Name:GILMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RACHEL CARSON WAY
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9395
Mailing Address - Country:US
Mailing Address - Phone:607-229-6369
Mailing Address - Fax:
Practice Address - Street 1:602 IVY ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1646
Practice Address - Country:US
Practice Address - Phone:607-737-7804
Practice Address - Fax:607-735-7510
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012749-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant