Provider Demographics
NPI:1326330267
Name:KARSEN, ETHAN FORREST (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:FORREST
Last Name:KARSEN
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 1:2650 RIDGE AVE.
Mailing Address - Street 2:DEPT. OF PSYCHIATRY
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-425-6400
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE.
Practice Address - Street 2:DEPT. OF PSYCHIATRY
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-425-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT042.00128122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1022942Medicaid