Basic Information
Provider Information | |||||||||
NPI: | 1346218948 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OLSON | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 601 W 5TH AVE | ||||||||
Address2: | STE 400 | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992042705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093442663 | ||||||||
FaxNumber: | 5096249179 | ||||||||
Practice Location | |||||||||
Address1: | 601 W 5TH AVE | ||||||||
Address2: | STE 400 | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992042705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093442663 | ||||||||
FaxNumber: | 5096249179 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2006 | ||||||||
LastUpdateDate: | 11/26/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD00013246 | WA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 379109600 | 01 | WA | OWCP | OTHER | 8929872 | 01 | WA | CRIME VICTIMS | OTHER | 0000101463343 | 01 | ID | REGENCE BLUE SHIELD OF ID | OTHER | OL3345 | 01 | WA | ASURIS NW HEALTH | OTHER | 0261186 | 01 | WA | STATE L&I | OTHER | 1651207 | 05 | WA |   | MEDICAID | 513 | 01 | WA | GROUP HEALTH NW | OTHER | 200040946 | 01 | WA | RR MEDICARE | OTHER | KQ530 | 01 | ID | BLUE CROSS OF IDAHO | OTHER | 000010146343 | 01 | ID | REGENCE BLUE SHIELD OF ID | OTHER | 003864700I | 05 | ID |   | MEDICAID | 0072641 | 05 | MT |   | MEDICAID | 149065 | 01 | WA | DEPT OF LABOR & INDUSTRIE | OTHER |