1285693077 NPI number — MARIUS MAXWELL M.D.

Table of content: MARIUS MAXWELL M.D. (NPI 1285693077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285693077 NPI number — MARIUS MAXWELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAXWELL
Provider First Name:
MARIUS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1285693077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3650 LAKE OTIS PARKWAY, STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99508-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-222-6500
Provider Business Mailing Address Fax Number:
907-222-6550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3650 LAKE OTIS PKWY
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-5218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-222-6500
Provider Business Practice Location Address Fax Number:
907-222-6550
Provider Enumeration Date:
03/21/2006

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: 207T00000X , with the licence number:  5262 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: MD2011-0824 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 7202 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6100890 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 119113600 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 312588 . This is a "WYOMING BCBS PIN" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 24245 . This is a "ND BCBS PIN" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 4995818 . This is a "WELLMARK BCBS PIN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 3505619 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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