Healthcare Provider Details

I. General information

NPI: 1801335740
Provider Name (Legal Business Name): WELLSPRING PHYSICIAN, PC - NY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 09/02/2025
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 STATE ST
ALBANY NY
12207-2541
US

IV. Provider business mailing address

309 N WASHINGTON AVE SUITE 13
BRYAN TX
77803-5368
US

V. Phone/Fax

Practice location:
  • Phone: 877-872-0370
  • Fax: 855-908-2520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN J SOWERWINE
Title or Position: CMO
Credential: MD
Phone: 979-221-1398