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General NPI Number Information
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NPI Number | 1912005182
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Entity Type | Organization
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Legal Business Name | ADVANCED MEDICAL CLINIC P A
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 07/02/2012
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Provider Practice Location Address
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Address Line | 3347 STATE RD7 SUITE 206
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City | WELLINGTON
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State | FL
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Zip | 33449-8095
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Country | US
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Telephone | 561-434-1935
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Fax | 561-434-3169
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Provider Business Mailing Address
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Address Line | 3347 STATE ROAD 7 SUITE 206
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City | WELLINGTON
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State | FL
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Zip | 33449-8095
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Country | US
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Telephone | 561-434-1935
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Fax | 561-434-3169
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Authorized Official
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Title or Position | PRESIDENT & CEO
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Name | DR. ISHAN A GUNAWARDENE
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Credential | MD
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Telephone | 561-434-1935
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME81674
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License Number State | FL
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