=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861578619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARY S. OLSON, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 10/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 DOCTORS PARK
-----------------------------------------------------
City | CAPE GIRARDEAU
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63703-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-334-9498
-----------------------------------------------------
Fax | 573-332-0370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 DOCTORS PARK
-----------------------------------------------------
City | CAPE GIRARDEAU
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63703-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-334-9498
-----------------------------------------------------
Fax | 573-332-0370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | BETH MOSHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-334-9498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | R3A32
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------