MEDICARE: DANIEL LEE MAXWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician	080787	GA

General Provider Information

NPI Number	:	1205071552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL LEE MAXWELL

Provider Business Mailing Address
First Line	:	150 CLINIC AVE STE 101
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-4402
Country	:	US
Telephone Number	:	770-834-0873
Fax Number	:	770-834-6118

Provider Business Practice Location Address
First Line	:	150 CLINIC AVE STE 101
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-4402
Country	:	US
Telephone Number	:	770-834-0873
Fax Number	:	770-834-6118

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2008
Last Update Date	:	10/04/2018

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