Basic Information
| Provider Information | |||||||||
| NPI: | 1588715320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSEN | ||||||||
| FirstName: | BLAINE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 ELDORADO BLVD | ||||||||
| Address2: | SUITE 6250 | ||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800213408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032720751 | ||||||||
| FaxNumber: | 3033182488 | ||||||||
| Practice Location | |||||||||
| Address1: | 1960 OGDEN ST | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802183666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033182500 | ||||||||
| FaxNumber: | 3033182575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 02/26/2013 | ||||||||
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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 | 40689 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 60023236 | 05 | CO | MEDICAID | P01094996 | 01 | CO | RR MCR - ESJH | OTHER |