Active NPI
Douglas Craig Maibenco, MD PHD
- Surgery Physician
- Decatur, IL
National Provider Identifier
1366424061
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgery Physician
- License
- 036098825
- Practice address
- 1730 E Lake Shore Dr
Decatur, IL 62521-3809 - Phone
- (217) 329-1000
- Fax
- (217) 329-1055
- NPI assigned
- Nov 17, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgery Physician | 208600000X | 036098825 | IL | Primary |
Addresses
Primary practice location
1730 E Lake Shore Dr
Decatur, IL 62521-3809
Mailing address
1730 E Lake Shore Dr
Decatur, IL 62521-3809
Phone (217) 329-1000
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036098825 | Medicaid | IL | |
| CI8411 | Other | MEDICARE TRAVELERS |
Electronic endpoints 1
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | dmaibenco100758@ewd.direct.hshs.org | Direct |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine, Doctor of Philosophy
Interoperability endpoints
- dmaibenco100758@ewd.direct.hshs.org
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1132185600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1641427200000",
"number": "1366424061",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1730 E LAKE SHORE DR",
"city": "DECATUR",
"state": "IL",
"postal_code": "625213809",
"telephone_number": "217-329-1000",
"fax_number": "217-329-1055"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1730 E LAKE SHORE DR",
"city": "DECATUR",
"state": "IL",
"postal_code": "625213809",
"telephone_number": "217-329-1000",
"fax_number": "217-329-1055"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MAIBENCO",
"first_name": "DOUGLAS",
"middle_name": "CRAIG",
"credential": "MD PHD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-11-17",
"last_updated": "2022-01-06",
"certification_date": "2022-01-06",
"status": "A"
},
"taxonomies": [
{
"code": "208600000X",
"taxonomy_group": "",
"desc": "Surgery",
"state": "IL",
"license": "036098825",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036098825",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE TRAVELERS",
"identifier": "CI8411",
"state": null
}
],
"endpoints": [
{
"endpointType": "DIRECT",
"endpointTypeDescription": "Direct Messaging Address",
"endpoint": "dmaibenco100758@ewd.direct.hshs.org",
"affiliation": "N",
"use": "DIRECT",
"useDescription": "Direct",
"contentType": "OTHER",
"contentTypeDescription": "Other",
"contentOtherDescription": "CDA/CCD/TXT",
"address_1": "1730 E Lake Shore Dr",
"city": "Decatur",
"state": "IL",
"country_code": "US",
"postal_code": "625213809",
"country_name": "United States",
"address_type": "DOM"
}
],
"other_names": []
}Other providers in Decatur, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.