Basic Information
| Provider Information | |||||||||
| NPI: | 1255322301 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | ALLAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4602 DEPT | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601220021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062254821 | ||||||||
| FaxNumber: | 9062254537 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 W FAIR AVE | ||||||||
| Address2: | SUITE 36 | ||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498552675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062253864 | ||||||||
| FaxNumber: | 9062253851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 02/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101006715 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080129239 | 01 | MI | RAILROAD MEDICARE | OTHER | AO006715 | 05 | MI | MEDICAID |