Provider Demographics
NPI:1225032147
Name:OLSON, BRAD A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:A
Last Name:OLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 BRIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-3900
Mailing Address - Country:US
Mailing Address - Phone:567-702-1090
Mailing Address - Fax:
Practice Address - Street 1:2250 CHAPEL AVE W STE 120
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2051
Practice Address - Country:US
Practice Address - Phone:856-421-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074948207RA0401X
OHOH35074948O208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000141665OtherBLUE CROSS BLUE SHIELD PI
OH2078988Medicaid