Provider Demographics
NPI:1750590550
Name:OLSEN, GRANT JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:JOSEPH
Last Name:OLSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GRANT
Other - Middle Name:JOSEPH
Other - Last Name:OLSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:225 S PINE ST FL 2
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2365
Mailing Address - Country:US
Mailing Address - Phone:812-524-4265
Mailing Address - Fax:812-524-4269
Practice Address - Street 1:225 S PINE ST FL 2
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2365
Practice Address - Country:US
Practice Address - Phone:812-524-4265
Practice Address - Fax:812-524-4269
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064374A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200883280Medicaid
IN941010DDMedicare PIN