Basic Information
| Provider Information | |||||||||
| NPI: | 1851320618 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KURT F. OLSEN, M.D.,S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8135 N MILWAUKEE AVE | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607142828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479671149 | ||||||||
| FaxNumber: | 8479678594 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126548700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 07/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | OLSEN | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8479671149 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01636421 | 01 | IL | BLUE SHIELD OF ILLINOIS | OTHER |