Healthcare Provider Details

I. General information

NPI: 1457451601
Provider Name (Legal Business Name): WOMENS ROOM OBGYN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 OUTER MAIN ST NATCO BUILDING
POTSDAM NY
13676-2324
US

IV. Provider business mailing address

445 FACTORY ST PO BOX 91
WATERTOWN NY
13601-2729
US

V. Phone/Fax

Practice location:
  • Phone: 315-265-2153
  • Fax: 315-265-2540
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number156476
License Number StateNY

VIII. Authorized Official

Name: JAMES P LYONS JR.
Title or Position: OWNER DIRECTOR
Credential: M.D.
Phone: 315-265-2153