Provider Demographics
NPI:1336292572
Name:OLNES, ANDREW L (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:L
Last Name:OLNES
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 1:700 E ALICE ST
Mailing Address - Street 2:P.O. BOX 400
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-4925
Mailing Address - Country:US
Mailing Address - Phone:208-785-1200
Mailing Address - Fax:208-785-8516
Practice Address - Street 1:700 E ALICE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-4925
Practice Address - Country:US
Practice Address - Phone:208-785-1200
Practice Address - Fax:208-785-8516
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM62752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1250802Medicare ID - Type Unspecified