Healthcare Provider Details

I. General information

NPI: 1356344741
Provider Name (Legal Business Name): RONALD KEVIN OLM DPM, FACFAS, C-PED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4246 3 MILE RD N
TRAVERSE CITY MI
49686-9195
US

IV. Provider business mailing address

4246 3 MILE RD N
TRAVERSE CITY MI
49686-9195
US

V. Phone/Fax

Practice location:
  • Phone: 231-922-9100
  • Fax: 231-922-9180
Mailing address:
  • Phone: 231-922-9100
  • Fax: 231-922-9180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901001664
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberR0001664
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: