Basic Information
| Provider Information | |||||||||
| NPI: | 1669420949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | LUCILA | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 36500 S GRATIOT AVE | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480351772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864933732 | ||||||||
| FaxNumber: | 5864933739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301058057 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3225102 | 05 | MI | MEDICAID | 350D410030 | 01 | MI | BCBS BCN COMM BLUE | OTHER | 3225096 | 05 | MI | MEDICAID | 4956934 | 05 | MI | MEDICAID | 1022817 | 01 | MI | MHP HAN | OTHER | 4682809 | 05 | MI | MEDICAID |