Provider Demographics
NPI:1861498438
Name:KATSNELSON, ROMAN (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:KATSNELSON
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 1:66 POWERHOUSE RD
Mailing Address - Street 2:FL 3
Mailing Address - City:ROSLYN HTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1324
Mailing Address - Country:US
Mailing Address - Phone:516-626-6366
Mailing Address - Fax:
Practice Address - Street 1:5401 OLD COURT RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5103
Practice Address - Country:US
Practice Address - Phone:410-521-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053836207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD585501200Medicaid
MD454M660FOtherTRAILBLAZER
MD454M660FOtherTRAILBLAZER
MD585501200Medicaid