Healthcare Provider Details

I. General information

NPI: 1487608451
Provider Name (Legal Business Name): JORGEN PER OLSSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 GORMAN AVE
ELKINS WV
26241-3181
US

IV. Provider business mailing address

812 GORMAN AVE
ELKINS WV
26241-3181
US

V. Phone/Fax

Practice location:
  • Phone: 304-636-3300
  • Fax: 304-637-3435
Mailing address:
  • Phone: 304-637-3948
  • Fax: 304-636-0672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number030173
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number24514
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: