Healthcare Provider Details

I. General information

NPI: 1851077127
Provider Name (Legal Business Name): IAN MAXWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 WALNUT ST STE 200
PHILADELPHIA PA
19103-5426
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 155-458-7172
  • Fax: 215-545-9355
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT031566
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: