MEDICARE: DR. PETER W OLSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	PO040103	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407807217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER W OLSON M.D.

Provider Business Mailing Address
First Line	:	100 MICHIGAN ST NE
Second Line	:	MC845
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2560
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 68TH ST SE
Second Line	:	SUITE 200
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-7896
Country	:	US
Telephone Number	:	616-267-8100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	05/22/2012

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