Basic Information
| Provider Information | |||||||||
| NPI: | 1790713543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1400 JEFFERSON RD | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550573081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076639000 | ||||||||
| FaxNumber: | 6512410775 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 JEFFERSON RD | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550573081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076639000 | ||||||||
| FaxNumber: | 6512410775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 29720 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 378877600 | 05 | MN | MEDICAID | 54035OL | 01 | MN | BCBS | OTHER | 010050518 | 01 | GA | RAILROAD MEDICARE | OTHER | N003453 | 01 | MN | CHAMPUS | OTHER |