Provider Demographics
NPI:1275511305
Name:MCCAW, MAXHN H (DO)
Entity Type:Individual
Prefix:
First Name:MAXHN
Middle Name:H
Last Name:MCCAW
Suffix:
Gender:M
Credentials:DO
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 338
Mailing Address - Street 2:415-11TH AVE.
Mailing Address - City:ORION
Mailing Address - State:IL
Mailing Address - Zip Code:61273-0338
Mailing Address - Country:US
Mailing Address - Phone:309-526-3111
Mailing Address - Fax:309-526-3740
Practice Address - Street 1:415 11TH AVE
Practice Address - Street 2:
Practice Address - City:ORION
Practice Address - State:IL
Practice Address - Zip Code:61273
Practice Address - Country:US
Practice Address - Phone:309-526-3111
Practice Address - Fax:309-526-3740
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059253208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059253Medicaid
IL036059253Medicaid
IL212068Medicare ID - Type Unspecified