Provider Demographics
NPI:1114979598
Name:WELLNESS PHYSICIAN CARE PLLC
Entity Type:Organization
Organization Name:WELLNESS PHYSICIAN CARE PLLC
Other - Org Name:QUIKMED URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROACHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-785-7009
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-0091
Mailing Address - Country:US
Mailing Address - Phone:315-782-4207
Mailing Address - Fax:315-782-8699
Practice Address - Street 1:727 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4031
Practice Address - Country:US
Practice Address - Phone:315-785-7009
Practice Address - Fax:315-785-8566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02779344Medicaid
NY02779344Medicaid