=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508825456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE A MAXWELL D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3551 E OVERLAND RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-6757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-1333
-----------------------------------------------------
Fax | 208-489-5188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1128
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83701-1128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-381-2222
-----------------------------------------------------
Fax | 208-463-3044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | O0385
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------