Healthcare Provider Details

I. General information

NPI: 1518027853
Provider Name (Legal Business Name): MARK ANDREW MAXWELL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 OGLETHORPE AVE BLDG 500
ATHENS GA
30606-2179
US

IV. Provider business mailing address

PO BOX 6890
EVANSVILLE IN
47719-0890
US

V. Phone/Fax

Practice location:
  • Phone: 706-549-9244
  • Fax: 706-549-6102
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA001859
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: