Healthcare Provider Details

I. General information

NPI: 1255061982
Provider Name (Legal Business Name): MAXWELL KENNEDY HAGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N ROCK RD
DERBY KS
67037-3705
US

IV. Provider business mailing address

1010 N KANSAS ST
WICHITA KS
67214-3124
US

V. Phone/Fax

Practice location:
  • Phone: 316-788-6963
  • Fax:
Mailing address:
  • Phone: 316-293-2665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94-11087
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: