Healthcare Provider Details

I. General information

NPI: 1972508711
Provider Name (Legal Business Name): GERALD S MAXWELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5533 MAHONING AVE
AUSTINTOWN OH
44515-2366
US

IV. Provider business mailing address

5533 MAHONING AVE
AUSTINTOWN OH
44515-2366
US

V. Phone/Fax

Practice location:
  • Phone: 330-793-2701
  • Fax: 330-793-2366
Mailing address:
  • Phone: 330-793-2701
  • Fax: 330-793-2366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS9661
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-006824
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: