Healthcare Provider Details

I. General information

NPI: 1326052515
Provider Name (Legal Business Name): IAN WEST MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 MAIN ST STE 110
CHESTER MD
21619-2792
US

IV. Provider business mailing address

1630 MAIN ST STE 110
CHESTER MD
21619-2792
US

V. Phone/Fax

Practice location:
  • Phone: 410-643-3410
  • Fax: 410-643-3461
Mailing address:
  • Phone: 410-643-3410
  • Fax: 410-643-3461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number20621
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: