=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740504877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLEAN CARDIOLOGY P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2010
-----------------------------------------------------
Last Update Date | 03/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38 N MAIN ST - RT 16 SUITE 2
-----------------------------------------------------
City | DELEVAN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14042-9501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-707-2112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 908 NIAGARA FALLS BLVD SUITE 208
-----------------------------------------------------
City | NORTH TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14120-2019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-692-3302
-----------------------------------------------------
Fax | 716-332-3525
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/OWNER
-----------------------------------------------------
Name | CYRIL GUNAWARDANE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 716-707-2112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 171403
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------