Provider Demographics
NPI:1962495812
Name:MEDICAL LABORATORY OF OLEAN
Entity Type:Organization
Organization Name:MEDICAL LABORATORY OF OLEAN
Other - Org Name:MLO DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BABU
Authorized Official - Middle Name:A
Authorized Official - Last Name:BHAWSAR
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:716-373-2670
Mailing Address - Street 1:2626 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1858
Mailing Address - Country:US
Mailing Address - Phone:716-373-2670
Mailing Address - Fax:716-373-2673
Practice Address - Street 1:2626 W STATE ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1858
Practice Address - Country:US
Practice Address - Phone:716-373-2670
Practice Address - Fax:716-373-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPFI3746291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPFI3746OtherSTATE LICENSE NUMBER
PA0014835380001Medicaid
NY01200908Medicaid
NYPFI3746OtherSTATE LICENSE NUMBER