Basic Information
| Provider Information | |||||||||
| NPI: | 1811985658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLGAARD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893620153 | ||||||||
| FaxNumber: | 9893624683 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | AU GRES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487038700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898767104 | ||||||||
| FaxNumber: | 9898762881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101008757 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3516709 | 05 | MI | MEDICAID |