Healthcare Provider Details

I. General information

NPI: 1700875788
Provider Name (Legal Business Name): RANDALL V OLSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E BROADWAY
COLUMBIA MO
65201-5844
US

IV. Provider business mailing address

PO BOX 3242
INDIANAPOLIS IN
46206-3242
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-8000
  • Fax: 573-815-6343
Mailing address:
  • Phone: 844-295-4873
  • Fax: 844-839-0626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number6035963-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number6035963-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number6035963-1205
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number11771
License Number StateNV
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2017004467
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2017004467
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: