Basic Information
| Provider Information | |||||||||
| NPI: | 1093705642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9142 | ||||||||
| Address2: | MASS GENERAL PHYSICIAN ORGANIZATION | ||||||||
| City: | CHARLESTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021299142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177240287 | ||||||||
| FaxNumber: | 6177262894 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 OCEAN AVE | ||||||||
| Address2: | REVERE HEALTH CARE CENTER RHC | ||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021513675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814856000 | ||||||||
| FaxNumber: | 7814856392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 70597 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | J11049 | 01 | MA | BCBS MA | OTHER | 3082113 | 05 | MA | MEDICAID | 070597 | 01 | MA | TUFTS HEALTH PLAN | OTHER |