Basic Information
| Provider Information | |||||||||
| NPI: | 1962690743 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IAN MYERS, MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
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| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219220190 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 BOW ST | ||||||||
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| City: | ELKTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219215544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103984000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 11/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | CORNELL | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CRED COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4103984679 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0059266 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00070381 | 01 | MEDICARE RAILROAD | OTHER |