1669505004 NPI number — GORDON S OLSEN DO PC

Table of content: (NPI 1669505004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669505004 NPI number — GORDON S OLSEN DO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GORDON S OLSEN DO PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669505004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 796
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HEBER CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84032-0796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-789-0096
Provider Business Mailing Address Fax Number:
307-789-0860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 ARROWHEAD DRIVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82930-9266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-789-0096
Provider Business Practice Location Address Fax Number:
307-789-0860
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OLSEN
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
S
Authorized Official Title or Position:
ORTHOPEDIC SURGEON
Authorized Official Telephone Number:
307-789-0096

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00593001 . This is a "BCBS" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 122536700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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