Provider Demographics
NPI:1750330437
Name:OLSON, RICK LANE (MD)
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:LANE
Last Name:OLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICKY
Other - Middle Name:L
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9330 MEDICAL PLAZA DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:843-847-3225
Mailing Address - Fax:843-847-3247
Practice Address - Street 1:9330 MEDICAL PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-847-3225
Practice Address - Fax:843-847-3247
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC221147Medicaid
SCG779857524Medicare ID - Type Unspecified
SCG77985Medicare UPIN
SC221147Medicaid