MEDICARE: DR. RUSSELL G OLSEN DPM

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	213E00000X	Podiatrist	106765-0501	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	1069500001	OTHER	UT	RR MEDICARE DME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	870545030OL1	OTHER	UT	EDUCATORS MUTUAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	528688204001	OTHER	UT	BLUECROSS PPO
5	73654	OTHER	UT	INTERMOUNTAIN HEALTH CARE
6	167286	OTHER	UT	DMBA

General Provider Information

NPI Number	:	1639178882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL G OLSEN DPM

Provider Business Mailing Address
First Line	:	1811 W ROYAL HUNTE DR
Second Line	:	SUITE 2
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-8273
Country	:	US
Telephone Number	:	435-586-2225
Fax Number	:	435-867-1909

Provider Business Practice Location Address
First Line	:	1811 W ROYAL HUNTE DR
Second Line	:	SUITE 2
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-8273
Country	:	US
Telephone Number	:	435-586-2225
Fax Number	:	435-867-1909

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

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	12/28/2007

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Directions to “ DR. RUSSELL G OLSEN DPM” Practice Location

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