MEDICARE: DR. HARRY RUSSELL MAXON III M.D.

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	207R00000X	Internal Medicine Physician	35.035304	OH
2	207U00000X	Nuclear Medicine Physician	35.035304	OH

General Provider Information

NPI Number	:	1437111309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HARRY RUSSELL MAXON III M.D.

Provider Business Mailing Address
First Line	:	13 PAINTED BUNTING RD
Second Line	:
City	:	HILTON HEAD ISLAND
State	:	SC
Zip	:	29928-5601
Country	:	US
Telephone Number	:	843-363-6680
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 INGLESIDE AVE
Second Line	:	SUITE 5B
City	:	CINCINNATI
State	:	OH
Zip	:	45206-4400
Country	:	US
Telephone Number	:	513-961-1973
Fax Number	:

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

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	05/23/2010

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