=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265449516
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAROLD CRAIG MAXEY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2006
-----------------------------------------------------
Last Update Date | 06/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1102 WEST 32ND STREET
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-347-1111
-----------------------------------------------------
Fax | 417-347-2149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2102 FAIRWAY DR
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64804-0093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-626-8763
-----------------------------------------------------
Fax | 417-626-8763
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | R-4011
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 18504
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 117870
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------