Basic Information
| Provider Information | |||||||||
| NPI: | 1689669541 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OLEAN MEDICAL GROUP PARTNERSHIP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163720141 | ||||||||
| FaxNumber: | 7163736632 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163720141 | ||||||||
| FaxNumber: | 7163736632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | STRADE | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7163720141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 03012159 | 05 | NY | MEDICAID |