1457035933 NPI number — SHELLY MAXWELL PA

Table of content: SHELLY MAXWELL PA (NPI 1457035933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457035933 NPI number — SHELLY MAXWELL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAXWELL
Provider First Name:
SHELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457035933
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 LAPEER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48607-1203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-759-6464
Provider Business Mailing Address Fax Number:
989-399-8233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3884 MONITOR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48706-9298
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-671-2000
Provider Business Practice Location Address Fax Number:
989-671-4000
Provider Enumeration Date:
06/14/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  TBD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 5601011947 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)