Healthcare Provider Details

I. General information

NPI: 1023317245
Provider Name (Legal Business Name): MAXX ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MARTIN ST
PRESQUE ISLE ME
04769-2238
US

IV. Provider business mailing address

PO BOX 4860
MURRELLS INLET SC
29576-2698
US

V. Phone/Fax

Practice location:
  • Phone: 843-651-2624
  • Fax: 843-357-4940
Mailing address:
  • Phone: 843-651-2624
  • Fax: 843-357-4940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL T MITCHELL
Title or Position: BUSINESS MANAGER
Credential:
Phone: 843-651-2624