Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RA0401X | Internist - Addiction Medicine | 35074948 | OH |
Y | 208000000X | Pediatrician | OH35074948O | OH |
NPI | 1225032147 |
---|---|
Provider Name | Dr. Brad A Olson |
First Address | Perrysburg, OH 43551-3900 |
Second Address | Cherry Hill, NJ 08002-2051 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2005 |
Last Update Date | 24/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000141665 | BLUE CROSS BLUE SHIELD PI (01) | OH |
2078988 | (05) | OH |