MEDICARE: OLSON PEDIATRIC CLINIC, LLC

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	2080A0000X	Pediatric Adolescent Medicine Physician

General Provider Information

NPI Number	:	1588902902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLSON PEDIATRIC CLINIC, LLC

Provider Business Mailing Address
First Line	:	16463 BOONES FERRY RD
Second Line	:	SUITE 400
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4259
Country	:	US
Telephone Number	:	503-635-3743
Fax Number	:	503-636-7404

Provider Business Practice Location Address
First Line	:	16463 BOONES FERRY RD
Second Line	:	SUITE 400
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4259
Country	:	US
Telephone Number	:	503-635-3743
Fax Number	:	503-636-7404

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	ELIZABETH GRAFF
Credential	:	M.D.
Telephone Number	:	503-635-3743

Provider Enumeration Date	:	01/18/2013
Last Update Date	:	01/18/2013

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