Healthcare Provider Details

I. General information

NPI: 1528185451
Provider Name (Legal Business Name): SANDRA JANE OLSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST 20TH FLOOR
CHICAGO IL
60611-5975
US

IV. Provider business mailing address

220 E WALTON PL
CHICAGO IL
60611-1649
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-7950
  • Fax:
Mailing address:
  • Phone: 312-664-1019
  • Fax: 312-664-8304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: