=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205862687
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL K OLPIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 E KINCAID ST
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98274-4126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-424-4111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 97
-----------------------------------------------------
City | BOW
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98232-0097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MD00012192
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------