Basic Information
| Provider Information | |||||||||
| NPI: | 1265449516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAXEY | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2102 FAIRWAY DR | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648040093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176268763 | ||||||||
| FaxNumber: | 4176268763 | ||||||||
| Practice Location | |||||||||
| Address1: | 1102 WEST 32ND STREET | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173471111 | ||||||||
| FaxNumber: | 4173472149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 06/29/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | R-4011 | AR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 18504 | LA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 117870 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 243419306 | 05 | MO | MEDICAID | 100084100A | 05 | OK | MEDICAID | 200362940B | 05 | KS | MEDICAID | 204642102 | 05 | MO | MEDICAID |