Healthcare Provider Details

I. General information

NPI: 1841916665
Provider Name (Legal Business Name): IAN P MCDONNELL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14825 N OUTER 40 RD STE 300
CHESTERFIELD MO
63017-0002
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 636-812-1211
  • Fax: 636-812-0159
Mailing address:
  • Phone: 630-575-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2022030884
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: