Healthcare Provider Details

I. General information

NPI: 1790448512
Provider Name (Legal Business Name): MAXWELL MEDICAL GROUP, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 RAYMOND DR. SUITE 5
NORTHBROOK IL
60062
US

IV. Provider business mailing address

4336 WEST ENFIELD
SKOKIE IL
60076
US

V. Phone/Fax

Practice location:
  • Phone: 855-629-8353
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANDREW ROSENSON
Title or Position: PRESIDENT
Credential: MD
Phone: 847-814-9955