Healthcare Provider Details

I. General information

NPI: 1194884353
Provider Name (Legal Business Name): JOHN KEVIN MAXWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE # 1611
MIAMI FL
33136-1005
US

IV. Provider business mailing address

PO BOX 114
FALLON MT
59326-0114
US

V. Phone/Fax

Practice location:
  • Phone: 406-939-0391
  • Fax:
Mailing address:
  • Phone: 406-939-0391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberME168491
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License NumberME168491
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME168491
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberME168491
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME168491
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberME168491
License Number StateFL
# 7
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME168491
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: