1518907740 NPI number — DR. BRAD L OLSON MD

Table of content: DR. BRAD L OLSON MD (NPI 1518907740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518907740 NPI number — DR. BRAD L OLSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
BRAD
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1518907740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2608 S ELMWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-4344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-333-0203
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 S CLIFF AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57104-5275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-338-7098
Provider Business Practice Location Address Fax Number:
605-335-3505
Provider Enumeration Date:
06/07/2006

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: 207L00000X , with the licence number:  3747 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0003453 . This is a "BLUE CROSS SD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 5700080 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 935551 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5T115OL . This is a "BLUE CROSS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 324225100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".