1295722668 NPI number — RALPH MARTIN MAXWELL DO

Table of content: RALPH MARTIN MAXWELL DO (NPI 1295722668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295722668 NPI number — RALPH MARTIN MAXWELL DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAXWELL
Provider First Name:
RALPH
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1295722668
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 HIGHWAY 65 S
Provider Second Line Business Mailing Address:
PO BOX 830
Provider Business Mailing Address City Name:
DUMAS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71639-3006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-382-8261
Provider Business Mailing Address Fax Number:
870-382-8140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 HIGHWAY 65 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUMAS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71639-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-382-8261
Provider Business Practice Location Address Fax Number:
870-382-8140
Provider Enumeration Date:
09/30/2005

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: 207Q00000X , with the licence number:  00356 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0194584 . This is a "DEPT OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: S5494 . This is a "BLUE CROSS OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807073500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010149459 . This is a "REGENCE BS OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8434870 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00192008 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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