Provider Demographics
NPI: | 1477567576 |
---|---|
Name: | OLSON, MICHAEL D (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | D |
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: | 200 1ST ST SW |
Mailing Address - Street 2: | |
Mailing Address - City: | ROCHESTER |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55905-0001 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 507-284-2511 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 200 1ST ST SW |
Practice Address - Street 2: | |
Practice Address - City: | ROCHESTER |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55905-0001 |
Practice Address - Country: | US |
Practice Address - Phone: | 507-284-2511 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-27 |
Last Update Date: | 2020-08-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 70947 | 207Y00000X |
MN | 1063258 | 363A00000X |
MN | 56673 | 207Y00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 944616800 | Medicaid | |
MN | 944616800 | Medicaid | |
MN | H400095428 | Medicare PIN | |
MN | 970002473 | Medicare PIN |