Provider Demographics
NPI:1760448591
Name:OLSEN, SAMUEL JOHN II (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOHN
Last Name:OLSEN
Suffix:II
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:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331-0325
Mailing Address - Country:US
Mailing Address - Phone:423-263-2444
Mailing Address - Fax:423-263-1553
Practice Address - Street 1:301 GRADY RD
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331-0325
Practice Address - Country:US
Practice Address - Phone:423-263-2444
Practice Address - Fax:423-263-1553
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN039591207R00000X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3330104Medicaid
TN4108690OtherBCBS
TNP00237341OtherMEDICARE RR
I14288Medicare UPIN
TN3330104Medicare PIN