Provider Demographics
NPI:1457399248
Name:OLSON, ELLEN T (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:T
Last Name:OLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 N CENTRAL AVE
Mailing Address - Street 2:1600
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4527
Mailing Address - Country:US
Mailing Address - Phone:602-744-4765
Mailing Address - Fax:602-744-4799
Practice Address - Street 1:1850 N CENTRAL AVE
Practice Address - Street 2:1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4527
Practice Address - Country:US
Practice Address - Phone:602-744-4765
Practice Address - Fax:602-744-4799
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40418207L00000X
WAMD00040224207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8317463Medicaid
AZ360623Medicaid
P00842063OtherMEDICARE RAILROAD
P00842063OtherMEDICARE RAILROAD
WAGAB39390Medicare PIN
AZ360623Medicaid