Healthcare Provider Details

I. General information

NPI: 1952007114
Provider Name (Legal Business Name): ELIS YNGVE OLSON, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 01/31/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 W. DIVERSEY PKWY SUITE G
CHICAGO IL
60614
US

IV. Provider business mailing address

1440 W TAYLOR ST # 227
CHICAGO IL
60607-4623
US

V. Phone/Fax

Practice location:
  • Phone: 331-472-7443
  • Fax:
Mailing address:
  • Phone: 331-472-7443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KARIL ANN WALTHER
Title or Position: VICE PRESIDENT PRACTICE OPERATIONS
Credential:
Phone: 608-235-7970