=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679795025
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4039 RTE 219 SUITE 103
-----------------------------------------------------
City | SALAMANCA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14779-9625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-945-0368
-----------------------------------------------------
Fax | 716-945-0757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4039 RTE 219 SUITE 103
-----------------------------------------------------
City | SALAMANCA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14779-9625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-945-0368
-----------------------------------------------------
Fax | 716-945-0757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | SRINIVAS P THANDLA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 716-945-0368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 237701
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------