Basic Information
Provider Information | |||||||||
NPI: | 1114979598 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLNESS PHYSICIAN CARE PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | QUIKMED URGENT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 91 | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 136010091 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157824207 | ||||||||
FaxNumber: | 3157828699 | ||||||||
Practice Location | |||||||||
Address1: | 727 WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | WATERTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 136014031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157857009 | ||||||||
FaxNumber: | 3157858566 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 04/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROACHE | ||||||||
AuthorizedOfficialFirstName: | EDMUND | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3157857009 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 02779344 | 05 | NY |   | MEDICAID |