Individual
MARILYN A. MAXWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
3660 VISTA AVE, SAINT LOUIS, MO 63110-2540
(314) 977-6100
(314) 977-6137
Mailing address
3691 RUTGER ST, PROVIDER ENROLLMENT, SAINT LOUIS, MO 63110-2515
(314) 977-6828
(314) 977-6777
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
R1D74
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
202218012
—
MO
Enumeration date
08/14/2006
Last updated
03/30/2009
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