Provider Demographics
NPI:1972585818
Name:MAXIM DIAGNOSTIC CENTER, LLC
Entity type:Organization
Organization Name:MAXIM DIAGNOSTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-341-3016
Mailing Address - Street 1:2618 E BANKHEAD HWY
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-9558
Mailing Address - Country:US
Mailing Address - Phone:817-341-3016
Mailing Address - Fax:817-341-2394
Practice Address - Street 1:2618 E BANKHEAD HWY
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-9558
Practice Address - Country:US
Practice Address - Phone:817-341-3016
Practice Address - Fax:817-341-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXFTX195Medicare ID - Type Unspecified