Basic Information
| Provider Information | |||||||||
| NPI: | 1447330410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEILSON | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 US ROUTE 1 | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073968600 | ||||||||
| FaxNumber: | 2073968632 | ||||||||
| Practice Location | |||||||||
| Address1: | 887 CONGRESS ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076625555 | ||||||||
| FaxNumber: | 2076625526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 11/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | 5423 | AK | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0120X | MD18028 | ME | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 30208266 | 05 | NH | MEDICAID | 433399099 | 05 | ME | MEDICAID | MD98332 | 05 | AK | MEDICAID |