=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487895579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CATHERINE L WELLS MD, PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2009
-----------------------------------------------------
Last Update Date | 08/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 TROY SCHENECTADY RD SUITE 114
-----------------------------------------------------
City | LATHAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12110-2442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-786-1600
-----------------------------------------------------
Fax | 518-786-1606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 711 TROY SCHENECTADY RD SUITE 201
-----------------------------------------------------
City | LATHAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12110-2442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-213-0478
-----------------------------------------------------
Fax | 518-782-3799
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 265000
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------