Healthcare Provider Details

I. General information

NPI: 1821007451
Provider Name (Legal Business Name): CHARLES S OLSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 MICHIGAN AVE
GLADSTONE MI
49837-1929
US

IV. Provider business mailing address

128 MICHIGAN AVE
GLADSTONE MI
49837-1929
US

V. Phone/Fax

Practice location:
  • Phone: 906-428-4084
  • Fax: 906-428-1881
Mailing address:
  • Phone: 906-428-4084
  • Fax: 906-428-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101013811
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: