Provider Demographics
NPI:1447231048
Name:MAXWELL, THERESE A (MD)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:A
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 1:1504 N THORNTON AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8394
Mailing Address - Country:US
Mailing Address - Phone:706-226-0508
Mailing Address - Fax:706-226-5889
Practice Address - Street 1:1504 N THORNTON AVE
Practice Address - Street 2:STE 102
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8394
Practice Address - Country:US
Practice Address - Phone:706-226-0508
Practice Address - Fax:706-226-5889
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023637207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D68959Medicare UPIN