1063489839 NPI number — ROGER M OLANDER MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063489839 NPI number — ROGER M OLANDER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLANDER
Provider First Name:
ROGER
Provider Middle Name:
M
Provider Name Prefix Text:
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:
1063489839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
990 SOUTH AVE
Provider Second Line Business Mailing Address:
SUITE 104A
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-244-2084
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
990 SOUTH AVE
Provider Second Line Business Practice Location Address:
SUITE 104A
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-244-2084
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2006

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: 207V00000X , with the licence number:  134145 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102294CK . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5983343 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10459448 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6094 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00484299 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P010134145 . This is a "BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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