Healthcare Provider Details

I. General information

NPI: 1336292572
Provider Name (Legal Business Name): ANDREW L OLNES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E ALICE ST
BLACKFOOT ID
83221-4925
US

IV. Provider business mailing address

700 E ALICE ST P.O. BOX 400
BLACKFOOT ID
83221-4925
US

V. Phone/Fax

Practice location:
  • Phone: 208-785-1200
  • Fax: 208-785-8516
Mailing address:
  • Phone: 208-785-1200
  • Fax: 208-785-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM6275
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: