Provider Demographics
NPI:1912005182
Name:ADVANCED MEDICAL CLINIC P A
Entity Type:Organization
Organization Name:ADVANCED MEDICAL CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ISHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUNAWARDENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-434-1935
Mailing Address - Street 1:3347 STATE ROAD 7
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8095
Mailing Address - Country:US
Mailing Address - Phone:561-434-1935
Mailing Address - Fax:561-434-3169
Practice Address - Street 1:3347 STATE RD7
Practice Address - Street 2:SUITE 206
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33449-8095
Practice Address - Country:US
Practice Address - Phone:561-434-1935
Practice Address - Fax:561-434-3169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33244OtherBCBS GROUP
FLDF6667OtherRR MEDICARE
FL33244OtherBCBS GROUP