Provider Demographics
NPI:1376634949
Name:OLSEN, KEVIN H (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:H
Last Name:OLSEN
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 1:2603 STAFFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-3608
Mailing Address - Country:US
Mailing Address - Phone:570-558-5558
Mailing Address - Fax:
Practice Address - Street 1:2603 STAFFORD AVENUE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-3608
Practice Address - Country:US
Practice Address - Phone:570-558-5558
Practice Address - Fax:570-558-5557
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042779E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011413170012Medicaid
PA0011413170012Medicaid
408773Medicare ID - Type Unspecified