Provider Demographics
NPI:1659454882
Name:MAXWELL, EDWARD NISBET JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:NISBET
Last Name:MAXWELL
Suffix:JR
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 1:2333 ALUMNI PARK PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4012
Mailing Address - Country:US
Mailing Address - Phone:859-257-7910
Mailing Address - Fax:
Practice Address - Street 1:245 FOUNTAIN CT STE 225
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1888
Practice Address - Country:US
Practice Address - Phone:859-257-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY162782084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64162787Medicaid
0054303Medicare PIN
KY64162787Medicaid