Healthcare Provider Details

I. General information

NPI: 1659127934
Provider Name (Legal Business Name): HKSM MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27407 N 58TH DR
PHOENIX AZ
85083-1266
US

IV. Provider business mailing address

27407 N 58TH DR
PHOENIX AZ
85083-1266
US

V. Phone/Fax

Practice location:
  • Phone: 602-663-3830
  • Fax:
Mailing address:
  • Phone: 602-663-3830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SETH CALEB MAXWELL
Title or Position: CEO
Credential: MD
Phone: 602-663-3830