1619963311 NPI number — DR. ELAINE ELIZABETH OLSON MD

Table of content: DR. ELAINE ELIZABETH OLSON MD (NPI 1619963311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619963311 NPI number — DR. ELAINE ELIZABETH OLSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
ELAINE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1619963311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1226
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARK RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-793-8890
Provider Business Mailing Address Fax Number:
847-793-8892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 VILLAGE GREEN DR
Provider Second Line Business Practice Location Address:
#220
Provider Business Practice Location Address City Name:
LINCOLNSHINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60069-3095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-793-8890
Provider Business Practice Location Address Fax Number:
847-793-8894
Provider Enumeration Date:
09/27/2005

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: 208VP0014X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 21621708 . This is a "BLUECROSS BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 21621708 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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