Healthcare Provider Details

I. General information

NPI: 1376634949
Provider Name (Legal Business Name): KEVIN H OLSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 STAFFORD AVENUE
SCRANTON PA
18505-3608
US

IV. Provider business mailing address

2603 STAFFORD AVE
SCRANTON PA
18505-3608
US

V. Phone/Fax

Practice location:
  • Phone: 570-558-5558
  • Fax: 570-558-5557
Mailing address:
  • Phone: 570-558-5558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD042779E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0011413170012
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: