Provider Demographics
NPI:1811990906
Name:OLSON, LYNN D (MD)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:D
Last Name:OLSON
Suffix:
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 1:165 NATCHEZ TRACE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7947
Mailing Address - Country:US
Mailing Address - Phone:270-782-7800
Mailing Address - Fax:270-843-0779
Practice Address - Street 1:165 NATCHEZ TRACE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7947
Practice Address - Country:US
Practice Address - Phone:270-782-7800
Practice Address - Fax:270-843-0779
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21044207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64210446Medicaid
KY000000050854OtherANTHEM
KY000000050854OtherANTHEM
KYC71971Medicare UPIN
KY0645104Medicare ID - Type UnspecifiedRUSSELLVILLE MEDICARE