Provider Demographics
NPI:1659511202
Name:MAXWELL, RYAN (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:MAXWELL
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 1:101 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-4763
Mailing Address - Country:US
Mailing Address - Phone:215-527-0571
Mailing Address - Fax:
Practice Address - Street 1:2400 N ROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3655
Practice Address - Country:US
Practice Address - Phone:815-971-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015922207L00000X
NY288918207L00000X
IL036.144123207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036144123Medicaid
PA102723767Medicaid
NJ0308137Medicaid
WI1659511202Medicaid