Healthcare Provider Details

I. General information

NPI: 1659572733
Provider Name (Legal Business Name): KEVIN H. OLSEN M.D. PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 STAFFORD AVE
SCRANTON PA
18505-3608
US

IV. Provider business mailing address

2603 STAFFORD AVENUE
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: 570-558-5557

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: DR. KEVIN H OLSEN
Title or Position: PRESIDENT
Credential: MD
Phone: 570-558-5558