=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760448591
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL JOHN OLSEN II MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2006
-----------------------------------------------------
Last Update Date | 11/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 GRADY RD
-----------------------------------------------------
City | ETOWAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37331-0325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-263-2444
-----------------------------------------------------
Fax | 423-263-1553
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 325
-----------------------------------------------------
City | ETOWAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37331-0325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-263-2444
-----------------------------------------------------
Fax | 423-263-1553
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 039591
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 039591
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------