Provider Demographics
NPI:1487604542
Name:MAXWELL, JON MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:MICHAEL
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1582
Mailing Address - Country:US
Mailing Address - Phone:517-263-0575
Mailing Address - Fax:517-265-5188
Practice Address - Street 1:227 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1582
Practice Address - Country:US
Practice Address - Phone:517-263-0575
Practice Address - Fax:517-265-5188
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJM051623207X00000X
OH35070366207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1959306Medicaid
MI2004600521OtherMI BCBSM
MID64977001Medicare ID - Type Unspecified
MIA74881Medicare UPIN
MI0D64977Medicare ID - Type Unspecified
MI1959306Medicaid