Healthcare Provider Details

I. General information

NPI: 1417249293
Provider Name (Legal Business Name): MICAH JOEL MAXWELL MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST THE BLOOMBERG CHILDREN'S CENTER, RM 11379
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

1800 ORLEANS ST THE BLOOMBERG CHILDREN'S CENTER, RM 11379
BALTIMORE MD
21287-0010
US

V. Phone/Fax

Practice location:
  • Phone: 410-614-5055
  • Fax:
Mailing address:
  • Phone: 410-614-5055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberD0079065
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: