Provider Demographics
NPI:1063734200
Name:MAXWELL AESTHETICS PC
Entity type:Organization
Organization Name:MAXWELL AESTHETICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-751-1225
Mailing Address - Street 1:2490 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6522
Mailing Address - Country:US
Mailing Address - Phone:520-751-1225
Mailing Address - Fax:520-751-2008
Practice Address - Street 1:2490 E RIVER RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6522
Practice Address - Country:US
Practice Address - Phone:520-751-1225
Practice Address - Fax:520-751-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41438174400000X
AZ21869174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty