Provider Demographics
NPI:1649265265
Name:MAXWELL, MARY (MD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 58TH AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4807
Mailing Address - Country:US
Mailing Address - Phone:970-495-0300
Mailing Address - Fax:970-224-9624
Practice Address - Street 1:1175 58TH AVE
Practice Address - Street 2:STE 202
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4807
Practice Address - Country:US
Practice Address - Phone:970-495-0300
Practice Address - Fax:970-224-9624
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26903207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01269034Medicaid
P00396253OtherRAILROAD MEDICARE
WY121925100OtherWYOMING MEDICAID
WY313017OtherBLUE SHIELD
COC448138Medicare PIN
WYW10257Medicare PIN
P00396253OtherRAILROAD MEDICARE
CO01269034Medicaid