Basic Information
Provider Information | |||||||||
NPI: | 1194122382 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OLEAN MEDICAL GROUP PARTNERSHIP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 535 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | OLEAN | ||||||||
State: | NY | ||||||||
PostalCode: | 147601500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7163720141 | ||||||||
FaxNumber: | 7163726421 | ||||||||
Practice Location | |||||||||
Address1: | 449 BROAD ST | ||||||||
Address2: |   | ||||||||
City: | SALAMANCA | ||||||||
State: | NY | ||||||||
PostalCode: | 147791455 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7169454770 | ||||||||
FaxNumber: | 7169452393 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2014 | ||||||||
LastUpdateDate: | 12/10/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEWIS | ||||||||
AuthorizedOfficialFirstName: | FRED | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | CHAIRMAN, EXECUTIVE BOARD | ||||||||
AuthorizedOfficialTelephone: | 7163720141 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.