Healthcare Provider Details

I. General information

NPI: 1164473534
Provider Name (Legal Business Name): STEFAN RANDOLPH MAXWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PENNSYLVANIA AVE SUITE 406
CHARLESTON WV
25302-3302
US

IV. Provider business mailing address

5 CHATHAM RD
CHARLESTON WV
25304-2763
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-2238
  • Fax: 304-388-2243
Mailing address:
  • Phone: 304-926-6428
  • Fax: 304-926-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number16172
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: