Healthcare Provider Details

I. General information

NPI: 1093402125
Provider Name (Legal Business Name): SAMUEL OLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SAM OLSON MD

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 MARYLAND AVE E
SAINT PAUL MN
55106-2824
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 651-772-3461
  • Fax:
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number77981
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: