Provider Demographics
NPI:1194779082
Name:KATZNELSON, IAN S (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:S
Last Name:KATZNELSON
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:PO BOX 388320
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-8320
Mailing Address - Country:US
Mailing Address - Phone:773-767-8283
Mailing Address - Fax:773-767-8320
Practice Address - Street 1:444 N NORTHWEST HWY
Practice Address - Street 2:STE 200
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3263
Practice Address - Country:US
Practice Address - Phone:847-825-2366
Practice Address - Fax:847-825-2513
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361067612084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615936OtherBLUE SHIELD
IL036106761Medicaid
ILP00218760OtherRAILROAD MEDICARE
IL036106761Medicaid
ILP00218760OtherRAILROAD MEDICARE