Provider Demographics
NPI:1437111309
Name:MAXON, HARRY RUSSELL III (MD)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:RUSSELL
Last Name:MAXON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 PAINTED BUNTING RD
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-5601
Mailing Address - Country:US
Mailing Address - Phone:843-363-6680
Mailing Address - Fax:
Practice Address - Street 1:2401 INGLESIDE AVE
Practice Address - Street 2:SUITE 5B
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-4400
Practice Address - Country:US
Practice Address - Phone:513-961-1973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2010-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.035304207R00000X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA75087Medicare UPIN