Healthcare Provider Details

I. General information

NPI: 1750720181
Provider Name (Legal Business Name): IAN CHRISTOPHER MCINNIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR PULMONARY DISEASE CLINIC
JBSA-FSH TX
78234
US

IV. Provider business mailing address

3551 ROGER BROOKE DR. SAN ANTONIO MILITARY MED CENTER, PULMONARY FELLOWSHIP
JBSA-FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-2153
  • Fax: 210-916-0709
Mailing address:
  • Phone: 210-916-5412
  • Fax: 210-916-0709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1290
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number1290
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number1290
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: