Healthcare Provider Details

I. General information

NPI: 1225082241
Provider Name (Legal Business Name): UPSTATE NEONATAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 WASHINGTON ST
WATERTOWN NY
13601
US

IV. Provider business mailing address

158 WOODRUFF ST
WATERTOWN NY
13601-4317
US

V. Phone/Fax

Practice location:
  • Phone: 315-785-4545
  • Fax: 315-785-4331
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KARL J KOMAR
Title or Position: PRESIDENT
Credential: MD
Phone: 315-785-4545