Basic Information
| Provider Information | |||||||||
| NPI: | 1710119425 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAXWELL | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2250 HAYES ST | ||||||||
| Address2: | STE 302 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157505995 | ||||||||
| FaxNumber: | 4156663144 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 HAYES ST | ||||||||
| Address2: | STE 302 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157505995 | ||||||||
| FaxNumber: | 4156663144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2009 | ||||||||
| LastUpdateDate: | 12/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A 109141 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | FM1583435 | 01 | CA | DEA# | OTHER | A109141 | 01 | CA | MEDICAL LICENSE# | OTHER | ZZZ92069Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | FHC 70042F | 01 | CA | SANTA CRUZ COUNTY MEDI-CAL PROVIDER # | OTHER |