Healthcare Provider Details

I. General information

NPI: 1073192274
Provider Name (Legal Business Name): MAXWELL BRICE PICKERING DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 WILLOW CREEK RD
PRESCOTT AZ
86301-1641
US

IV. Provider business mailing address

PO BOX 11720
PRESCOTT AZ
86304-1720
US

V. Phone/Fax

Practice location:
  • Phone: 928-771-5478
  • Fax: 928-771-5471
Mailing address:
  • Phone: 725-235-6794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL83638
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: