Provider Demographics
NPI:1659572733
Name:KEVIN H. OLSEN M.D. PC
Entity Type:Organization
Organization Name:KEVIN H. OLSEN M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-558-5558
Mailing Address - Street 1:2603 STAFFORD AVENUE
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:570-558-5557
Practice Address - Street 1:2603 STAFFORD AVE
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042779E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011413170012Medicaid
PA0011413170012Medicaid
PAC33568Medicare UPIN