Provider Demographics
NPI:1629716386
Name:OLSON, BIRK
Entity Type:Individual
Prefix:
First Name:BIRK
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 WOODBRIDGE AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-5130
Mailing Address - Country:US
Mailing Address - Phone:612-382-8112
Mailing Address - Fax:
Practice Address - Street 1:1880 WOODBRIDGE AVE STE C3
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-5130
Practice Address - Country:US
Practice Address - Phone:612-382-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty