Provider Demographics
NPI:1093211955
Name:HAYDEN, MAXWELL MARTIN
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:MARTIN
Last Name:HAYDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286-0297
Mailing Address - Country:US
Mailing Address - Phone:618-443-1337
Mailing Address - Fax:618-443-1383
Practice Address - Street 1:1300 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1048
Practice Address - Country:US
Practice Address - Phone:618-443-4138
Practice Address - Fax:618-443-2956
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-31
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL016005867213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program