Healthcare Provider Details

I. General information

NPI: 1952829178
Provider Name (Legal Business Name): MARY E MAXWELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 09/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 CLINIC AVE
CARROLLTON GA
30117-4413
US

IV. Provider business mailing address

119 AMBULANCE DR STE 202
CARROLLTON GA
30117-3857
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-9824
  • Fax: 770-836-9850
Mailing address:
  • Phone: 770-838-8710
  • Fax: 770-838-8563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: