Basic Information
Provider Information | |||||||||
NPI: | 1831383173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OLSEN | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10700 E GEDDES AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ENGLEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 801123800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037619190 | ||||||||
FaxNumber: | 7208744462 | ||||||||
Practice Location | |||||||||
Address1: | 10700 E GEDDES AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ENGLEWOOD | ||||||||
State: | CO | ||||||||
PostalCode: | 801123800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037619190 | ||||||||
FaxNumber: | 7208744462 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2007 | ||||||||
LastUpdateDate: | 04/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 46192 | AZ | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 53729 | CO | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 27860 | NE | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 04-37164 | KS | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD17657 | HI | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 1831383173 | 05 | MT |   | MEDICAID | 1831383173 | 05 | UT |   | MEDICAID | P01488708 | 01 | CO | RAILROAD MEDICARE | OTHER | 1831383173 | 05 | WY |   | MEDICAID | 43756786 | 05 | CO |   | MEDICAID | 24807001 | 05 | NM |   | MEDICAID | 100257090-00 | 05 | NE |   | MEDICAID | 100262774-00 | 05 | NE |   | MEDICAID | 100262776-00 | 05 | NE |   | MEDICAID | 1831383173 | 05 | IA |   | MEDICAID | 100262773-00 | 05 | NE |   | MEDICAID | 100262775-00 | 05 | NE |   | MEDICAID | 100262777-00 | 05 | NE |   | MEDICAID | 840897126-00 | 05 | NE |   | MEDICAID | 100262778-00 | 05 | NE |   | MEDICAID | 200546680A | 05 | OK |   | MEDICAID | 201098790A | 05 | KS |   | MEDICAID | 840597929-13 | 05 | NE |   | MEDICAID |