=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053582130
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH COUNTRY ALLERGY AND IMMUNOLOGY ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2008
-----------------------------------------------------
Last Update Date | 03/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 531 WASHINGTON ST SUITE 4122
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-4084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-782-4365
-----------------------------------------------------
Fax | 315-788-1932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 531 WASHINGTON ST SUITE 4122
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-4084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-782-4365
-----------------------------------------------------
Fax | 315-788-1932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LEWIS DAVID YECIES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 315-782-4365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 1407831
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------