Provider Demographics
NPI:1801876768
Name:MAXWELL, KENNETH SCRUGGS (MD)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SCRUGGS
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:110 CHARLOIS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1522
Mailing Address - Country:US
Mailing Address - Phone:336-768-3361
Mailing Address - Fax:336-768-4131
Practice Address - Street 1:110 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1522
Practice Address - Country:US
Practice Address - Phone:336-768-3361
Practice Address - Fax:336-768-4131
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9500660207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8955051Medicaid
NC040015067OtherRAILROAD MEDICARE
NC55051OtherBLUE CROSS BLUE SHIELD
NC54268OtherMEDCOST
NC6502393OtherVIRGINIA MEDICAID
NC9881OtherPARTNERS
NC1001971OtherUNITED HEALTHCARE
NC55051OtherBLUE CROSS BLUE SHIELD
NC2210937FMedicare ID - Type UnspecifiedMEDICARE