Basic Information
| Provider Information | |||||||||
| NPI: | 1386637858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLENCZAK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120A PROFESSIONAL CT | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217405852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017397900 | ||||||||
| FaxNumber: | 3017397112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120A PROFESSIONAL COURT | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217405848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017397900 | ||||||||
| FaxNumber: | 3017397112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD035098E | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | MD035098E | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | D0063781 | MD | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5700680 | 05 | MD | MEDICAID |