Provider Demographics
NPI:1427164995
Name:OLANDER, TINA (MD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:OLANDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-464-4460
Mailing Address - Fax:414-464-7074
Practice Address - Street 1:10950 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-1110
Practice Address - Country:US
Practice Address - Phone:414-464-4460
Practice Address - Fax:414-464-7074
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41174207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32571200Medicaid
WI32571200Medicaid
WI68480Medicare ID - Type Unspecified