MEDICARE: MAXIM DIAGNOSTIC CENTER, LLC

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	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1972585818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAXIM DIAGNOSTIC CENTER, LLC

Provider Business Mailing Address
First Line	:	2618 E BANKHEAD HWY
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76087-9558
Country	:	US
Telephone Number	:	817-341-3016
Fax Number	:	817-341-2394

Provider Business Practice Location Address
First Line	:	2618 E BANKHEAD HWY
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76087-9558
Country	:	US
Telephone Number	:	817-341-3016
Fax Number	:	817-341-2394

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MR. WILLIAM MACKNIGHT
Credential	:
Telephone Number	:	817-341-3016

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	08/22/2020

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