Provider Demographics
NPI:1821196783
Name:LYLE T OLSON MD INC
Entity Type:Organization
Organization Name:LYLE T OLSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:T
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-899-6877
Mailing Address - Street 1:200 BRADENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-7515
Mailing Address - Country:US
Mailing Address - Phone:614-793-1980
Mailing Address - Fax:
Practice Address - Street 1:659 PARK MEADOW RD STE J
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2879
Practice Address - Country:US
Practice Address - Phone:614-899-6877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH69178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0225312Medicaid
OHG21834Medicare UPIN
OHLYSP02481Medicare ID - Type Unspecified