1902903800 NPI number — WOMACK PRIMARY MEDICAL CARE, PLLC

Table of content: (NPI 1902903800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902903800 NPI number — WOMACK PRIMARY MEDICAL CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOMACK PRIMARY MEDICAL CARE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902903800
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 RAILROAD AVE # 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BABYLON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11702-2204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-277-0051
Provider Business Mailing Address Fax Number:
631-277-2690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 MONTAUK HWY
Provider Second Line Business Practice Location Address:
STE 111
Provider Business Practice Location Address City Name:
WEST ISLIP
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11795-4429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-277-0051
Provider Business Practice Location Address Fax Number:
631-277-2690
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOMACK
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
H
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
631-277-0051

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  223075 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3298766 . This is a "AETNA/US HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 153114 . This is a "VYTRA HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02214588 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00165433 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2912790 . This is a "OXFORD HEALTH PLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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