1225020746 NPI number — MARK A OLSON M.D.

Table of content: (NPI 1407828932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225020746 NPI number — MARK A OLSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1225020746
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29900 LORRAINE AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48093-5266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-582-0864
Provider Business Mailing Address Fax Number:
586-582-0964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11012 E 13 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48093-2572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-573-6880
Provider Business Practice Location Address Fax Number:
586-573-2562
Provider Enumeration Date:
08/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  4301044866 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1997933 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700E021830 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700F340300 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MO044866 . This is a "BCBS PIN #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700E021910 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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