Basic Information
| Provider Information | |||||||||
| NPI: | 1831400746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | OLIVIA | ||||||||
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| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 EAST PENN SQUARE | ||||||||
| Address2: | THE WANAMAKER BLDG., 9TH FL., N | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259320 | ||||||||
| FaxNumber: | 2674259331 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | SUITE 9329 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901858 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2010 | ||||||||
| LastUpdateDate: | 03/27/2018 | ||||||||
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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 | 390200000X | BB5204071-ON4 | MA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | MA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207LP3000X | MD460796 | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1033208840001 | 05 | PA | MEDICAID |