=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407878119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE WOMENS HEALTH SVC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 11/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 622 WASHINGTON STREET
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-788-2003
-----------------------------------------------------
Fax | 315-788-7087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 91
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-782-4207
-----------------------------------------------------
Fax | 315-782-8699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | WALTER DODARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-788-2003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------