Provider Demographics
NPI:1447330410
Name:NEILSON, IAN R (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:R
Last Name:NEILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7609
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:887 CONGRESS ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3100
Practice Address - Country:US
Practice Address - Phone:207-662-5555
Practice Address - Fax:207-662-5526
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK54232086S0120X
MEMD180282086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30208266Medicaid
ME433399099Medicaid
AKMD98332Medicaid
ME00906702Medicare PIN
AKMD98332Medicaid
ME000906702Medicare PIN
ME433399099Medicaid