Provider Demographics
NPI:1366475931
Name:OLLI, RANDY SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:SHANE
Last Name:OLLI
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 1:325 E H ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4760
Mailing Address - Country:US
Mailing Address - Phone:906-774-3300
Mailing Address - Fax:
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:906-774-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060059207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G71004OtherRHC BC NUMBER
MI0G76001OtherMEDICARE
MI0G76001OtherMEDICARE
MI0G71004OtherRHC BC NUMBER