Provider Demographics
NPI:1922091503
Name:MACCOLLUM, MAXWELL S III (MD)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:S
Last Name:MACCOLLUM
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M.S.
Other - Middle Name:
Other - Last Name:MACCOLLUM
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 80217
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0217
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:480-418-3323
Practice Address - Street 1:10450 W MCDOWELL RD
Practice Address - Street 2:STE 102
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4802
Practice Address - Country:US
Practice Address - Phone:623-846-1746
Practice Address - Fax:623-846-0993
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18546207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ286642Medicaid
AZ3Z3988OtherHEALTHNET
AZP00845666Medicare PIN
AZZ136786Medicare PIN